Welcome! Please read the following important information carefully!
You will be directed to the online form after confirming that you have read and understand the information below.
We ask that you complete each page of the online comprehensive form and submit it to us so we may schedule your initial appointment. We will call the number provided to schedule once we have received and reviewed your forms. This may take up to a week to complete. If it is convenient for you, we also request the following:
- All laboratory results for previous 2 years – Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP), Cholesterol Panel (HDL, LDL, Total Cholesterol), any thyroid and/or hormone studies, any special food sensitivity testing, saliva, and/ or stool testing.
- For women: mammograms, PAP results, and yearly exams for previous 2 years
- For men: prostate screening and yearly exams for previous 2 years
If you are not conveniently able to locate these items and your clinician would require them to continue care, we will have to complete an authorization to release medical records form at your first appointment to obtain them. If these tests have not been completed recently, our clinician can order what she feels is necessary for you at the time of your appointment.
We also ask that you bring the following to you initial consultation:
- Most recent insurance card
- Photo ID
- List of medications and supplements. Please bring in the supplements so that we may see the ingredients and please remember to also list them on your initial paperwork.
Please arrive 15 minutes prior to your appointment. If you arrive 10 minutes or more PAST your scheduled appointment time, you may be asked to reschedule to maximize your time with your clinician. If you are unable to keep your appointment, please call at least 72 hours in advance of your scheduled appointment date to cancel or reschedule. Failure to show to the appointment or notify the office 72 hours in advance will result in a no show/late cancellation fee of $200. Please know that we are unable to provide supervision for young children that accompany you to our clinic and we ask that you make other arrangements.
Thank you for allowing us to be a part of your health care team. We look forward to meeting you soon!
Wellness is Waiting!
Integrative Health and Hormone Clinic Staff
Important Office Policies
For prescription refill requests ordered by Dr. Gray simpy have your pharmacy fix the request to our office at (319) 363-4411. Please allow at least ONE WEEK for this process or any other prescriptions request.
We greatly appreciate our patients, and work hard to ensure each patient is our top priority during appointments. We make every efforts to respond to questions and/or concerns presented outside of an appointment within 3-5 business days.
Supplement Discount Cards are great way to save on supplements. When you spend $200 on supplements, you will receive $20 off your NEXT PURCHASE. Supplement Discount Cards cannot be combined with any other offer.
We make every effort to see our patients in a timely manner, but we often have many on the waiting list for an appointment time. To help us, we ask that you please notify the office 72 hours in advance if you need to change or reschedule your appointment.
A $200.00 NO SHOW fee will be charged for initial appointments without the 72 hour notice. A $100.00 NO SHOW fee will be charged for follow-up appointments without the 72 hour notice.
We also ask that all patients are 15 minutes early to their appointments, so we may stay on schedule and prevent patients from waiting too long when they arrive.
All specimens collected in this office are sent to LabCorp.
If you would like us to send any medical records to your primary care physician, please allow us 3-5 business days.
Patient Rights and Responsibilities
A patient has the right to:
- Be treated with courtesy and respect, with appreciation of his/her individual dignity and with protection of his/her need for privacy.
- A prompt and reasonable response to questions and requests. Please allow at least 72 hoursfor us to respond to your non-urgent questions.
- Know what rules and regulations apply to his/her conduct.
- Be given, by his/her healthcare providers, information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis.
- Receive upon request and in advance of treatment, a reasonable estimate of charges for medical care.
- Know, upon request and in advance of treatment, that Integrative Health and Hormone Clinic is a direct-pay practice.
- Receive a copy of a reasonable clear and understandable itemized bill and, upon request, have the charges explained.
- Receive impartial access to medical treatment or accommodations, regardless of race, color, gender, ethnicity, national origin, religion, sexual orientation, physical handicap, or source of payment.
A patient has the responsibility to:
- Provide accurate and complete health information concerning his/her illness, hospitalization, medications, supplements, allergies, and all other pertinent items. The patient should bring any information relating to his/her health to Integrative Health and Hormone Clinic at the time of the visit.
- Understand that Integrative Health and Hormone Clinic is a specialty care provider and the services it provides are not meant to take the place of a primary care provider.Patient understands that he/she must notify his primary care provider, and any other health care provider of any and all supplements and hormones (including pellets) that Integrative Health and Hormone Clinic has prescribed, ordered, or inserted.
- Understand that as a specialty care provider, Integrative Health and Hormone Clinic does not offer emergency or urgent care. These services must be accessed at an urgent care facility or emergency room.
- Participate in the development of his/her care plan, and comply with Integrative Health and Hormone Clinic policies and procedures governing his/her care. The patient understands he/she may be discharged from services from non-adherence to this plan of care.
- Voice concerns or problems to Integrative Health and Hormone Clinic staff, and to request further information concerning anything he/she does not understand.
- Be respectful of other people of Integrative Health and Hormone Clinic property. This implies that no patients will be seen under the influence of drugs or alcohol.
- Realized the consequences of his/her actions if he/she refuses treatment or does not follow medical instructions.
- Remain under medical supervision as warranted by his/her condition.
- Abide by Integrative Health and Hormone Clinic rules and regulations, and ensure that those who accompany him/her do likewise.
- Provide truthful information about insurance status, notifying Integrative Health and Hormone Clinic of changes.
- Verify coverage of his/her insurance payer for annual physical examination coverage if requesting this be provided by Integrative Health and Hormone Clinic.
- Be considerate and cooperative with Integrative Health and Hormone Clinic staff and not discriminate against health care providers because of race, color, gender, ethnicity, nation origin, religion or sexual orientation.
- Arrive for appointments on time. If you are unable to arrive on time, it may be necessary to reschedule your appointment.
- Notify Integrative Health and Hormone 72 hours in advance if he/she is unable to keep a scheduled appointment. Integrative Health and Hormone Clinic will apply a $100 fee for all follow-up visits that are not rescheduled or cancelled 72 hours in advance.
- Permitted 1 Emergency Rescheduling: He/She will be able to reschedule 1 appointment due to an emergency within the 72 hour timeframe. He/She must reschedule in order to have the fee waived due to the emergency. Simply cancelling the appointment without the rescheduling will result in a $100 fee.
- Fulfill personal financial obligations of his/her healthcare are promptly as possible.
Regarding Treatment and Care
- I have elected to seek functional and integrative medicine treatment.
- I understand that in the practice of functional medicine some treatments are considered “alternative” by the conventional medical community and that there are some risks to treatment. I understand that some of the recommended treatments may not be approved by the FDA.
- I understand it is recommended that I see my primary care physician if I desire only FDA-approved treatments for my conditions.
- I understand that it is important that I provide accurate and complete health information concerning my illness, hospitalizations, medications, supplements, allergies, and other pertinent items.
- I understand that Integrative Health and Hormone Clinic is a specialty care provider and the services the Clinic provides are not meant to take the place of my primary care provider.
I further understand that I must notify my primary care provider, and any other health care provider, of any and all supplements and hormones (including pellets) that IHHC has prescribed, ordered, or inserted.
- IHHC has explained the risks and benefits concerning functional and integrative medicine and I have had a chance to have my questions answered.
Regarding Diet Recommendations and Nutritional/Herbal Supplements
- I hereby request nutritional consultation and supplement suggestions.
- We may make diet recommendations and recommendations regarding use of nutritional and herbal supplements in order to supply nutrition to support the physiological and biomechanical processes of the human body. Although these foods and products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function.
- Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.
- As a service to you, we make nutritional supplements available in our office. We purchase only top quality products and only from manufacturers who have gained our confidence through considerable research and experience. You are under no obligation to purchase these in our office but we cannot guarantee a similar quality from an outside source.
- Refunds will be given to any supplement that is unopened and returned within 14 days of purchase.
ANY QUESTIONS I HAVE HAD REGARDING THE CARE IHHC PROVIDES HAS BEEN ANSWERED TO MY SATISFACTION PRIOR TO MY SIGNING THIS CONSENT FORM. I HAVE MADE MY DECISION VOLUNTARILY AND FREELY. BY SIGNING THIS DOCUMENT BELOW, I ACKNOWLEDGE I HAVE READ AND AGREE TO ALL OF THE ABOVE STATEMENTS.
I HEREBY CERTIFY THAT I DO NOT REPRESENT ANY 3RD PARTY, INCLUDING, BUT NOT LIMITED TO, THE FDA, THE DEA, THE STATE BOARD OF MEDICINE, NURSING, OR STATE HEALTH DEPARTMENT.