Consent for Hormone Replacement
Welcome to my office!
My health goals for you are to enhance your present level of health while building a strong long-term
program to prevent Heart Disease, Osteoporosis, Alzheimer’s disease, and potentially, Diabetes and
some Cancers.
I encourage you to ask questions to make sure you understand what I do. I practice evidence-based
medicine based on good, sound, credible research. I seek to make information available to you so we can
be on the same page.
Your safety will always be my first concern. Secondarily are the short and long term benefits for you.
I only do preventative medicine so it is expected that you continue your disease care with your family
doctor and your health maintenance team.
Payment is expected at time of service. I do not accept insurance assignment. At the time of service, I will provide you with a super bill that you may submit from me as an out of network provider. If payment is
not possible at the time of service, it is important we talk before the service.
Patient Fees (as of January 1, 2020)
- $900.00 Vital Life Bio-identical Hormone Program, first year of service
- $300.00 Subsequent years service ongoing
- $165.00 Acute care, non Vital Life care, first thyroid only visit
- $90.00 Follow up visits for acute care etc., non Vital Life
Please check the box below, indicating that you have read and understand the above statements.
Patient Profile Intake Form
By completing this profile of your health history, I can offer you more complete naturopathic care.
Please be assured that I keep this information confidential.
Please indicate if a family member has had any of the following. If yes, please provide details at the end of this section.
Medications: Please indicate if you have used any of the following.
1. This is to acknowledge that I have been informed and understand that:
- Any treatment or advice provided to me as a patient of Michael Lang, ND is not mutually
exclusive from any treatment or advice that I may be receiving nor or in the future, from another health care provider.
- I am at liberty to seek or continue medical care from a physician, surgeon, or other health
care provider.
- I understand that Michael Lang, ND is not preventing me from seeking or following the advice of another licensed health care provider.
- The treatment and therapies provided to me by Michael Lang, ND may be different from those offered by another licensed health care provider.
2. I agree to pay for any fees for services, costs of supplements and homeopathic remedies, cost of
laboratory tests, or other fees at the time of the visit.
3. I hereby authorize and consent to treatment.
My name typed below give my consent.