Welcome!
It is our pleasure to welcome you to our office. We are committed to helping you and your family achieve the greatest improvement for your child(ren), through the most recent biological, medical, and nutritional advances.
Please make a note of the date and time of your child’s first appointment:
Scheduled for __________________________________________ @ _____________ with:
Dr. Bradstreet Dr. Rossignol Scott Smith, PA
Office (Melbourne) Office (California) Phone
For office appointments, please arrive 15 minutes before your scheduled time. For phone appointments, please call our office a few minutes before your scheduled time.
Due to the variability of insurance benefits, we are unable to bill insurance for you. We will however, assist you by providing invoices with coding and HCFA forms as needed, by request. You are responsible for payment for all services, and payment is due when services are rendered.
If you haven’t already done so, we encourage you to start your child on a gluten free/casein free diet. We see the most significant improvements in our patients who are on the GF/CF diet. We recommend the following resources:
1. Facing Autism by Lynn Hamilton
2. Special Diets for Special Kids by Lisa Lewis
Below is a list of documents included in this packet for your review. Each will be beneficial to you as you prepare for your first appointment. Please print them out, read them carefully, and save for your records.
*These forms must be completed and returned to our Melbourne Office.
1. Welcome letter
4. Notice of Privacy Practices
5. * Patient Consent for Use and Disclosure of Protected Health Information
6. * Consent for Treatment for Minors
7. * Consent for Treatment for Adults
8. * Laboratory Use Disclaimer
9. * Appointment Cancellation Policy
10.* Receipt of Appointment Cancellation Policy
12.* Patient Information
13. Map with directions to our Melbourne office
The following medical records and documents must reach our Melbourne office at least 3 weeks before your appointment. This will give us time to process your records and the doctor time to review them before your appointment.
□ Any lab results related to the reason for the appointment
□ Immunization Record
□ EEG, QEEG or MRI Records (no films, just the report)
□ Hospital Records (only for hospital stays related to the reason for the
Appointment)
□ Original diagnosis
□ Recent evaluation(s) either by a doctor, school, or therapist
□ Copy of Insurance Card, both sides, for outside lab referrals
□ The forms in this packet noted above with an *.
Please do not send us originals or your only copies.
Mail all documents to the following address:
Creation’s Own
Attention: Medical Records Department
3800 W. Eau Gallie Blvd., Suite 105
Melbourne, FL 32934
NOTE: All records must be mailed to our Florida office, regardless of whether your appointment is in Florida or California.
We are looking forward to working with you to improve your child’s health and well-being.
Sincerely,
Creation’s Own Staff