Mojo Thyroid Girlfriends – Intake Form

Please fill out the form below in its entirety prior to your appointment with Dr. Labbe. If you do not wish to fill out the form online please click here to download a printable copy (pdf). Submitting the following information acknowledges that you clearly understand that all services rendered are your responsibility and payment is expected at the time of service.

FILLING OUT THIS FORM CONFIRMS YOU CONSENT TO THE FOLLOWING: (click to expand)

  • I understand that the consultation process does not establish me as a patient under Dr. Labbe’s care and there is no doctor-patient relationship or obligation.
  • Please fill out all paperwork completely to the best of your knowledge.
  • The form below will require you to list the name and contact information of your physician.

HIPAA PRIVACY RULE (click to expand)

By completing the forms and submitting to Dr. Joni Labbe – you acknowledge receipt of the HIPAA Privacy Rule below.

The department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient in order to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records, and will do all we can to secure and protect your privacy. We strive to take all necessary precautions to protect that privacy. When it is appropriate and necessary, we provide the minimum necessary information only to those we feel are in need of your health care information, information about your treatment, payment, or health care operations.

We also want you to know that we grant your full access to your own personal medical records. We may have indirect treatment relationships with facilities (such as laboratories that only interact with physicians and not patients). We may have to disclose personal health information for purposes of treatment, payment, or health care operations to these facilities. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.
You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

  • Primary Complaints

  • This is a confidential patient symptom survey. Please check each condition which is true for you. If the condition does not apply to you or you do not understand a term or if you are not sure if a condition applies to you, then do not check the box. Use common sense. For example, Insomnia once in the last month probably isn’t that important and would not be marked. However, Insomnia occurring 1-2 times per week is notable and would be marked. Please take your time.
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  • General Health

  • Lifestyle Habits

  • Surgeries

  • Gastrointestinal

  • Respiratory

  • Mouth and Throat

  • Endocrine

  • Cardiovascular

  • Skin

  • Ears

  • Eyes

  • Feet

  • Neuromuscular

  • Behavior Patterns

  • Urinary

  • Men Only

  • Women Only

  • Medications

  • Please list all drugs you are currently taking including over the counter drugs, aspirin, etc. Also, list how long you have taken each drug and the condition for which it was prescribed.
  • Please list all drugs taken within the last five years including over the counter drugs, antibiotics, aspirin, inhalers, etc. Also, list how long you have taken each drug and the condition for which it was prescribed.
  • Please list all vitamins/herbs/supplements you are currently taking. Also, list how much of each supplement you are taking.
  • Thyroid Qualification Case History

  • This field is for validation purposes and should be left unchanged.