Appointment

To make an appointment, please complete the information on this page and submit.

________________________________________________________

Your Information

* = required field

*First name
*Last name
*Home phone
*Cell Phone or secondary phone
*Email
Reenter Email
Address
Apartment Number
City
State
Zip
Age
Name of parent/guardian (when pertinent)
Date of birth
Female/Male	Female Male
How did you hear about me?

________________________________________________________

Scheduling

Note from Dr. Doni: Please provide as many scheduling options as possible, including evenings and weekend days. This will make it more likely that I will be able to fit you into my schedule sooner. If we already arranged an appointment, please enter the date and time here. Otherwise, please enter dates and times that would work for you.

1. Please describe your availability and when you would like to be seen.

2. Would you like to be seen:

As soon as possible

Within one month

Within six months

3. Where would you like to be seen?

Manhattan

Port Jefferson, NY

Stamford, CT

________________________________________________________

Fees

Note from Dr. Doni: I have found that the fees listed here allow me to provide the effort and care necessary to be most successful in helping you, which is rewarding for me and exactly why you are choosing to see me. At the same time, I want to make sure that you have access to the care. If one of the options below does not work for you, please enter another amount that does work for you.

1. Initial Visit: Please select your choice for the first appointment.

Comprehensive
The comprehensive fees allow for extended consultation time, additional research, special accessibility by phone and detailed attention to your case. Recommended choice for the most comprehensive care and the best chances of curing your case.

Manhattan $495

Port Jefferson, NY and Stamford, CT $395

Standard
The standard visit includes a detailed consultation, review of your case, comprehensive recommendations and accessibility via email.

Manhattan $295

Port Jefferson, NY and Stamford, CT $195

Note from Dr. Doni: Cases are never denied for financial reasons. If you need special financial consideration, please email assistant@doctordoni.com to let us know. Please put "Attention Jackie" as the subject line of your email.

2. Follow Up Visits: Please select the fee you prefer for follow up visits.

Extended Manhattan $295

Extended Port Jefferson, NY and Stamford, CT $195

Manhattan follow up $145

Port Jefferson, NY and Stamford, CT follow up $95

Special Visit Types:
Phone Consult: Phone calls over 5 minutes in length are billed a minimum of $45. If you would like to arrange an initial or follow up visit by phone, please choose from the following options:

Comprehensive $195

Standard $95

Home Consult: Additional $50

________________________________________________________

Notes About Your Case

Please list your main health concerns. Let me know any information you think I should know about your case. Star those that are your highest priority to discuss first.

Please list current medications and dosages.
Prescription Medications:
Non-prescription Medications:
Vitamins/Herbs/Other:

Please list any allergies to foods, drugs or other allergens.
Please list and describe hospitalizations and surgeries.

Please list imaging and procedures with dates (x-rays, CT, MRI, ultrasound, DEXA, mammograms, EKG, colonoscopy, etc).

Did you have childhood immunizations?	yes no

Family History: Please indicate health concerns and, if deceased, cause of death, for the following relatives.
Mother
Mother’s mother
Mother’s father
Father
Father’s mother
Father’s father

Primary Health Care Provider:
*Name
Address
City
State
Zip
*Phone

________________________________________________________

Informed Consent
Additional Information About Services

Donielle Wilson, ND graduated from a five-year Naturopathic Medical Program at an accredited Naturopathic Medical School, Bastyr University in Seattle, Washington. She attained a doctorate degree as a Doctor of Naturopathic Medicine and a certificate in midwifery. Dr. Wilson is licensed as a Naturopathic Physician in Washington State and Connecticut. She received Bachelor's Degrees in nutrition and general science from Oregon State University.

New York State does not yet license Naturopathic Physicians to practice medicine. The practice of the profession of medicine is defined as diagnosing, treating, operating or prescribing for any human disease, pain, injury, deformity or physical condition. Donielle Wilson, ND is not an MD and does not practice medicine in the state of New York. Furthermore, her services are not meant to replace or to be a substitute for those of a licensed medical practitioner. If you seek the care of Dr. Wilson in New York, she advises that you seek the concurrent care of a health care provider licensed in New York State.

In New York State Dr. Wilson functions as a health consultant and focuses her practice on the enhancement of health. She uses her education and experience to give you suggestions. You agree to the physical contact necessary for assessment of your case and you make decisions that are right for you about whether to use her suggestions.

In Connecticut Dr. Wilson is a licensed Naturopathic Physician. She is licensed to diagnose and treat, perform physical exams and order labs and imaging. We may discuss substances that have not been subject to double blind clinical studies or FDA approval or regulation. You assume the responsibility for the decision to take any natural remedy. If you feel you are having any adverse reaction then stop taking all supplements immediately. If you are pregnant or nursing, confirm the safety of any supplements with your obstetrician or pediatrician. Recognize that, as an effect of the suggestions provided by Donielle Wilson, ND, the signs and symptoms of your medical condition(s) may diminish or disappear.

I have read and understand the information provided. I agree to the services provided by Donielle Wilson, ND.

Appointment

Your Information

Scheduling

Fees

Notes About Your Case

Informed ConsentAdditional Information About Services

Patient Testimonial

Informed Consent
Additional Information About Services