Home>Intake Paperwork>Pre-Screening Questionnaire

If requesting Dr Marinaro as your provider, please make sure you have read through the Integrative Concierge Care Policies and are prepared to enroll in the Active Care, New Patient Subscription.

Due to the high volume of new patients NENH receives, we have implemented a pre-screening process to ensure NENH is a good match for your needs as a patient. If you would like to become a new patient, please fill out the Pre-Screening Questionnaire and click “Submit” at the bottom of the page. Alternatively, you may click the link below to print out the form and send it to us or drop it off at our office.

Once we receive your Pre-Screening Questionnaire, we will review it and determine if NENH is a good match for your needs. NENH staff will then contact you to either schedule an initial consultation or give you suggestions for referrals. If NENH is a good match for your needs, we will schedule your New Patient Appointment.

*Please note that payment for the first appointment only is due at the time of booking.

Once your New Patient Appointment has been scheduled, please fill out and submit the Electronic Intake Paperwork (Adult or Pediatric, as appropriate for age), which can be found here.

New Patient Questionnaire

"*" indicates required fields

Name of the Patient Representative*

Legal name of patient:*

Birth Sex*

Date of Birth*

Preferred Pronoun*

Email Address:*

Phone #:*

Address*

What conditions are you looking to have assessed and treated?*

How did you hear about our practice?*

Have you ever worked with a Naturopathic Doctor before?*

Yes

Who have you worked with?*

Naturopathic Medicine utilizes functional testing and nutraceutical supplements that are not covered by insurance. Consultation fees may also not be covered by insurance and are due at the time of service. (Please verify coverage prior to your appointment.) Do you have the financial resources to cover out of pocket medical costs? (Please refer to our pricing and insurance page for further information.)*

Naturopathic Medicine is a collaboration between the doctor and the patient in which the patient does as much, if not more work than the doctor to heal. Are you willing to make changes to your lifestyle that will encourage the healing process?*

Naturopathic Doctors in the State of Maine serve as specialists only and are not primary care doctors. As such, we ask that all patients have a PCP or are actively seeking one. Do you have a primary care physician? Do you have a good relationship with your primary care doctor?*

What medical diagnosis have you received?*

NENH communicates with its patients through an electronic medical records system to maximize efficiency of our staff. Are you able to utilize email?*

Have you reviewed the Integrative Concierge Care model and policies?

Yes

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Pre-Screening Questionnaire

New Patient Questionnaire

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Some Recent Praise From Clients

-L.C.

-N.O.

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Integrative Concierge Care for the Treatment of Chronic Disease

Pre-Screening Questionnaire

New Patient Questionnaire

Order healthcare's best supplements

Some Recent Praise From Clients

-L.C.

-N.O.

-K.P.

-M.E.

-K.B.

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Integrative Concierge Care for the Treatment of Chronic Disease