New Client FormThank you for booking your appointment. Please complete the form below so we’re better prepared to assist you and maximize our time together. Parent's Name * First Name Last Name Child's Name * First Name Last Name Phone Number * (###) ### #### Email * Which city or state (or country if not US) do you reside? Child's age and DOB Child's Allergies What medical conditions does your child have? Has your child had any surgeries? Has your child ever been hospitalized? Has your child ever had to go to the ER for constipation or stomach issues? Any siblings with toileting problems? * Yes No At what age was your child potty trained? Enter 0 if not potty trained. * Does your child suffer from any of the following? Stool accidents Daytime urine accidents Overnight urine accidents How long ago did the stool soiling begin? * How often is your child having stool accidents currently? * Multiple times a day Daily Weekly Monthly Comes and goes Check all of the providers your child has seen regarding this issue: Pediatrician Ped GI Counselor Nutritionist Peds Pelvic Floor Physical Therapist Occupational Therapist Chiropractor Functional Medicine Doctor Doctor of Naturopathy Urologist Has your child had any testing regarding this problem (most children have not, but these tests may include things like lab work, xray, MRI, colonoscopy, motility testing, barium enema, rectal biopsy, celiac testing, etc)? When was last cleanout (if ever) and what meds and doses were used? What daily medicines or supplements are you currently using? Describe what treatments you have tried, what helped most, what helped least, etc. * If needed, would you consider suppositories? * Yes No Maybe Is there anything else you would like for us to know regarding your child? By signing below you agree to the following: I hereby consent and authorize The Encopresis Expert, LLC to assist in achieving toilet training for my child. I have voluntarily elected to undergo this consultant relationship between parent and The Encopresis Expert, LLC (hereby referred to as the consultant) after the goals and methods were explained to me. Prior to consultation, please check with your pediatrician to make sure your child is healthy and medically cleared to be toilet trained. This is a consulting service and is not in any manner considered a replacement or substitute for routine or urgent medical treatment. It is a requirement of this contract that your child continue their medical care with your pediatrician of choice and stay current with their well child examinations. If the need for additional testing arises, the child will be referred to their pediatrician for further evaluation and diagnostic testing, including abdominal radiographs, other specialized imaging, blood work, or other testing. In the event that I have additional questions regarding suggested supplements or positive behavioral interventions, I will contact the consultant immediately for clarification. I understand that my child may require more time and I may need more follow up appointments at an additional cost to achieve maximum results. I attest that I have given an accurate account of my child’s medical history including all known allergies, medical problems, prescription and over the counter medications or supplements being given. Any changes in the child’s health or medications or supplements will be conveyed to consultant in a timely manner. I agree that I have read and fully understand this agreement and all the information detailed above. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree not to hold The Encopresis Expert, LLC responsible or liable for any of my medical conditions that were present but not disclosed. I understand I have the right to refuse any suggestion or recommendation by the consultant. The consultant may terminate the agreement at any time for noncompliance, hostile behavior by the parent towards the consultant, or for any other reason. There will be no refunds given for early termination of care. While the consultant will make every effort to help you and your child through completion of the process, each child/family presents with its own unique circumstances, and as such, we cannot guarantee outcomes. I affirm that I am a parent or legal guardian for the child named above and authorized to make decisions for said child. Please type your full, legal name below to digitally sign this agreement. * We have received your information! We will be in contact soon and look forward to helping you and your child achieve your toiler training goals!
