• Dr Harbor is NOT taking new primary care patients. 
• Dr Harbor IS taking new patients who have chronic problems and want to visit her as a consulting physician.  These patients must have a different primary care physician.

To be scheduled you must agree to the following:

_____ I will provide a brief outline of my medical history.  Begin with when you felt good and include any pertinent changes.  Note  if and when you were in water damaged or moldy buildings or exposed to ticks.

_____ I will provide recent lab reports (lab test form) and any Lyme or immune system tests ( Lyme-immune form), as well as a list of all of your current medications and supplements (current medications form) when you come to your first appointment.

_____ I will keep a log of my symptoms. (symptom log)

_____ I will not smoke.

_____ I am willing to make dietary changes

_____ I have read, understand and have signed the consent to treatment form.

_____ I will bring a signed list of all medications and nutrients to every visit (medication & symptom diary)

_____ I understand that Dr Harbor does not prescribe pain medication. 

_____ I have read and agree to follow the communication guidelines. 

_____ I have read and agree to follow the financial and insurance policies. 

_____ I understand that I must have a primary care doctor who takes care of my ongoing health.

My doctor’s name and address:    
____________________________________________
____________________________________________
____________________________________________ 

_____ I DO wish for Dr Harbor to fax a copy of my medical information to my PCP.
_____I DO NOT wish for Dr Harbor to fax a copy of my medical information to my PCP. 

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Signature                                                                                                             Date