BAINBRIDGE NATUROPATHIC CLINIC
Dr. Christina Hinchcliffe, ND
123 Bjune Dr, Suite #111
Bainbridge Island, WA 98110
P: (206)842-2278 / F: (206)842-5206 / www.BainbridgeND.com
Welcome to Bainbridge Naturopathic Clinic. We will do our best to serve your healthcare needs, provide
natural and safe treatments, and serve as a resource for natural health education. It is important to us
that you read and understand our clinic policies. If you have questions about the policies, please be sure
to ask. We encourage you to communicate any issues, complaints or special needs with us.
CLINIC POLICIES
PAYMENT Payment is due at the time of service for office visits (non-insurance), copays and dispensary
items. We accept cash, checks, debit cards, health savings account (HSA) cards, Visa, Mastercard, and
American Express. Payment plans and sliding scales are available upon request.
INSURANCE It is your responsibility to make sure that your insurance policy covers the treatment you
are receiving. Please call your insurance company before your visit and get specific information
regarding your policy coverage.
If you are unable to find this information, please ask us and we can help you make sense of your
insurance. Please do this before your appointment to avoid unnecessary costs.
There are treatments we may do that aren’t covered by insurance, in which case you will be responsible
for payment. We will try to let you know before we perform any “uncovered services,” but they vary
from plan to plan and sometimes we are unaware that a specific plan won’t pay, in which case it will be
your responsibility.
I understand that I am financially responsible for all charges and agree to pay for services. If applicable, I
authorize the provider to release to my insurance company any information necessary to process a
claim. I authorize the insurance payment be made directly to the provider.
Initials __________Date __________
SUPPLEMENTS We stock a dispensary in our office and will recommend items that you can buy here.
However, we may also recommend you go elsewhere and you are not obliged to purchase directly from
Bainbridge Naturopathic Clinic. When you need refills, please call a few days ahead to make sure we’ve
got your items in stock. Sometimes, due to vendor back orders or other circumstances, we will not be
able to get the same item and will give you a similar product as a substitute.
If you need to pick items up when we are not in the office, we have a pick-up box outside of the clinic
where we will leave items for you when appropriate.
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
CONTACT US We prefer to be contacted via our main phone at (206) 842-4841 or fax (206) 842-5206.
You can also email for general information at info@bainbridgeND.com. However, we cannot provide
confidential information via this email address. You can also send emails to
DrHinchcliffe@medsecure.md and Dr. Hinchcliffe can send you a confidential secure reply. We are in
the office Tuesday-Friday from 9-5. Ashlee, our office manager, answers the phone from 9-3, but we
will retrieve messages left up to 5 every day.
If you have an urgent need to reach us after hours or during off days, follow the steps on the voicemail
prompt at our regular phone number of (206) 842-4841 in order to reach us.
CANCELLATION POLICY We are a small clinic and do our own scheduling. We appreciate if you give us
at least 48 hours notice before canceling an appointment so we have sufficient time to fill that spot.
Since we dedicate 30 minutes to 1 hour of our time for your appointment, if a time spot is empty as a
result of your late cancellation, it hurts our business. For this reason, if you cancel your appointment
with less than 48 hours notice, there is a $50.00 charge for your empty time slot. This is charged to you,
not your insurance. The charge will only be waived in emergency situations.
I have read and understand that if I cancel within 48 hours of an appointment, I will be liable for a
$50.00 cancellation charge.
Initials __________Date __________
NO SHOW POLICY If you make an appointment and don’t call or show up for that appointment (barring
emergency situations in which a call cannot be made) there is a charge of $50.00. This is charged to you
and not your insurance. We reserve the right to discontinue care to patients who no show and/or have a
late cancellation for three appointments.
I have read and understand the “No Show” policy and understand that if I fail to show up at my
scheduled appointed time, I will be charged $50.00.
Initials __________Date __________
CONFIDENTIALITY You have the right to know how your privacy is being protected in accordance with
the HIPAA Act of 1996. Your healthcare information is private and cannot be shared with anyone else
without your signed consent. Your records are kept in your chart and secured in our clinic at all times. If
charts are in the open, names are covered. Access to the clinic is limited to practitioners, employees,
and supervised guests.
I have read and understand my right to privacy, as stated above, and agree to allow Bainbridge
Naturopathic Clinic to maintain my records confidentially in accordance with the law.
PATIENT SIGNATURE _____________________________________________ DATE ________________
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
NEW PATIENT INTAKE FORM
PATIENT INFORMATION
Name _____________________________________ Date of Birth __________________ Age________
Address ___________________________________ City _______________ State _____ Zip _________
Home Phone ______________________ Cell_____________________ Work_____________________
Email ______________________________________ Social Security Number ______________________
Relationship Status: _____Married/Partnered _____Divorced/Separated _____Single/Widowed
Live with: ____Spouse ____Partner ____Relative/s ____Friend/s ____Parent/s ____Kid/s ____Pet/s
Emergency Contact ___________________________ Phone ___________________________________
How did you hear about us? ______________________________________________________________
Would you like to receive a copy of Dr. Hinchcliffe's bimonthly newsletter and updates on her blog
posting via email? Y / N
EMPLOYMENT INFORMATION
Employer _______________________________________ Position ______________________________
Address ________________________________________ Phone ________________________________
INSURANCE INFORMATION
Insurance Company/Plan Name ___________________________________________________________
ID Number/Claim Number ________________________________ Group Number _________________
Insurance Phone ____________________ Whose Policy is this (circle): Self Spouse Other
(If not self, please list name & date of birth of policy holder) ____________________________________
It is your responsibility to familiarize yourself with your insurance policy. If you are unsure whether you
have naturopathic coverage, please call your insurance company or check online to verify. It is important
to know if you have a deductible, if you have preventative care coverage, and which labs are covered by
your insurance. Copays are due at the time of service. Supplements are not covered by insurance.
_____ (initial) I understand that I am financially responsible for all charges and agree to pay for services
not covered by insurance.
_____ (initial) I authorize the provider to release to my insurance company or companies, any and all
information necessary to process any claim. I further authorize that payment/s be made directly to the
provider.
CONFIDENTIALITY You have the right to confidentiality when receiving care from providers. We will
not disclose medical information to anyone unless directed to do so in writing by you. If you would like
us to leave messages regarding your health care on an answering machine or with another person,
please list them below and indicate which voice mail we may leave messages on:
PATIENT SIGNATURE _____________________________________________ DATE ________________
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
YOUR CURRENT HEALTH
What is your main reason for coming in today? ______________________________________________
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MEDICAL HISTORY
What childhood illnesses have you had? ____________________________________________________
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What adult illnesses have you had? ________________________________________________________
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Previous surgeries and hospitalizations (include approximate dates): _____________________________
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Do you have any allergies to any drugs, herbs, foods, animals or other? ___________________________
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CURRENT MEDICATIONS/SUPPLEMENTS
Please list any medications, vitamins, herbs, supplements, or over-the-counter products you are taking:
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PATIENT SIGNATURE _____________________________________________ DATE ________________
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
FAMILY HISTORY OF HEALTH PROBLEMS (and age of death, if applicable)
Your Mother __________________________________________________________________________
Your Father ___________________________________________________________________________
Your Siblings __________________________________________________________________________
Maternal Grandparents _________________________________________________________________
Paternal Grandparents _________________________________________________________________
Children ______________________________________________________________________________
PERSONAL HABITS
What do you enjoy most in your life? ______________________________________________________
What are your main interests or hobbies? ___________________________________________________
Do you regularly use alcoholic beverages, how much? _________________________________________
Do you smoke (how much & for how long)? ________________________________________________
Do you use recreational drugs (which & how much)? __________________________________________
How often do you watch television? _______________________________________________________
Do you have a religious or spiritual practice? ________________________________________________
Do you enjoy your work? _____________________ Do you take vacations? _______________________
Do your work or hobbies expose you to toxic chemicals, heavy metals, mold or second hand smoke?
STRESS
On a scale of 1-10 (10 being high), how do you rate your average stress level? 0 1 2 3 4 5 6 7 8 9 10
What are the most significant stressors in your life or areas of disharmony?
SLEEP
On a scale of 1-10 (10 being great), how do you rate your sleep? 0 1 2 3 4 5 6 7 8 9 10
Do you have problems falling or staying asleep (which)? _______________________________________
How many hours do you sleep at night? ____________ Do you awaken refreshed?__________________
ENERGY
On a scale of 1-10 (10 being great), how do you rate your energy? 0 1 2 3 4 5 6 7 8 9 10
Are your daily tasks affected by your being tired? ____________________________________________
EXERCISE
What type, how much, & how often do you exercise? _________________________________________
DIET
Do you follow a special diet? _________________Do you eat at least 3 meals a day? ________________
Are you satisfied with your diet? ______________How much water do you drink daily? ______________
Do you drink soda or juice? N / Y, How much? _______________________________________________
Do you take in caffeine? N / Y, How much? _________________________________________________
Please list the foods/amounts you’ve eaten in the past 24 hours: ________________________________
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Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
PATIENT SIGNATURE _____________________________________________ DATE _________________
HEALTH CONCERNS (Please circle all items that are current or recent)
GENERAL: fever, night sweats, fatigue/tiredness, unusual weight gain or weight loss, appetite changes,
eating disorder, poor sleep, strong thirst, cravings, swelling of lymph nodes, food sensitivities or
allergies, cancer (if yes, what type ______________)
SKIN, HAIR, NAILS: rash, infection, growths/bumps, hair loss, itching, thinning/sensitive skin, acne, oily,
sores/lesions, eczema, sensitive skin, nail infection, dry hair, thin/brittle nails, ridged nails
HEAD, EYES, EARS, NOSE, THROAT: frequent headaches, migraines, vision problems, eye pain, double
vision, floaters/spots, eye redness/watery eyes, tearing problems, hearing loss, ringing, earache or ear
pain, itchy ears, hearing aids, frequent colds or flus, sinus problems or drainage, post nasal drip, hay
fever/allergies, loss of taste or smell, snoring, frequent sore or dry throat, hoarseness, sore or swollen
tongue, mouth or lip sores, dental problems, TMJ
CENTRAL NERVOUS SYSTEM: head injury, light-headedness, dizziness, convulsions, weakness/paralysis,
balance disturbance, trouble speaking
MUSCULOSKELETAL: joint or muscle pain/stiffness (if yes, where_____________), injury, muscle
cramps/spasms, muscle weakness, bone loss, loss of muscle mass
PERIPHERAL NERVOUS SYSTEM: loss of sensation or feeling in a body part, pins and needles sensations
in a body part
CARDIOVASCULAR AND CIRCULATION: chest pain or discomfort, high blood pressure, heart murmur,
palpitations, swelling, leg swelling, dizziness, history of heart attack or TIA/stroke/blood clots, history of
angina/chest pain, history of rheumatic fever, easy bruising, tendency to bleed easily or difficulty
stopping bleeding, nose bleeds, high cholesterol, varicose veins, spider veins, discolored extremities,
paleness, anemia
RESPIRATORY: cough, sputum, wheezing/asthma, chest pain, shortness of breath, rib pain
DIGESTION: heartburn, ulcer, abdominal pain, nausea, vomiting, blood/food/mucus/oil in stools, black
tarry stools, abdominal bloating, belching, excessive gas, bad breath, coating on tongue, hemorrhoids,
hepatitis, polyps, constipation, diarrhea, last colonoscopy (and results) _______
GENITOURINARY: pain with urination, urgency, frequency, dribbling, incontinence, bladder infections,
cloudy/foul smelling urine, kidney stones, blood in urine, urinating at night (if yes, how often?_______),
hernia, lower abdominal pain, sexually transmitted disease, urethral or genital discharge, genital sores
MALE: prostate inflammation, erectile difficulties, testicular pain or swelling, last digital prostate exam
(and results) _______, last PSA blood test (and results) ______
MENTAL-EMOTIONAL: depression, mood swings, anxiety, irritability, tearfulness, nervousness, tension,
phobias, compulsive behaviors, psychiatric disorder, suicidal thoughts/plan, diagnosed with or possible
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com
alcohol/drug dependency, worry, relationship problems, abusive relationship, elevated stress,
ADD/ADHD
ENDOCRINE: low thyroid function, overactive thyroid function, enlarged thyroid, thyroid with nodules,
low temperature, hot flashes, diabetes, low blood sugar, high blood sugar, sugar or salt cravings,
difficulty perspiring, rapid aging
FEMALE: heavy bleeding, painful bleeding, clots, PMS, PCOS, infertility, lack of bleeding, irregular cycles,
odor, itching, painful intercourse, sexual dysfunction, breast pain/lumps, lack of sex drive, fibroids,
ovarian cysts or PCOS, abnormal hair growth, birth control pills or injections, vaginal dryness,
hysterectomy (total or partial?), age of first period ___, age of last period___, number of
pregnancies___, number of children (ages) ___________________, last pap (and results) ____________,
last breast imaging (and results) ____________, last bone density scan (and results) ____________
PATIENT SIGNATURE _____________________________________________ DATE ________________
FINAL SIGNATURE/STATEMENT
“I__________________________________ have asked Dr. Christina Hinchcliffe, ND, of Bainbridge
Naturopathic Clinic, for help and I understand that the doctor will help to the best of her ability.”
PATIENT SIGNATURE _____________________________________________ DATE ________________
DOCTOR SIGNATURE _____________________________________________ DATE ________________
Bainbridge Naturopathic Clinic – (206)842-4841 – www.bainbridgenaturopathicclinic.com