Francis Holistic Medical Center

N. Thomas LaCava, MD, Medical Director                                             Treating the Cause of Complex Chronic Illness

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CHILDREN (patients who are younger than 16 years of age)


If your child is (or will be) a primary care pediatric patient of Dr. LaCava, please go to our other menu choice, Primary Care First Visit.

This page is for the responsible party for PEDIATRIC patients (children younger than 16 years of age) referred from another doctor who are seeing Dr. LaCava for their initial visit for a consulation.

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To set up an initial comprehensive visit with Dr. LaCava for your child, please contact our office by calling us at (508) 854-1380 during normal business hours. We are closed on Fridays and some Tuesdays.


We provide extra appointment time for first visits, so it is very important to let us know if you are not going to come to your appointment. Should you need to reschedule or cancel your appointment for any reason, please do so at least three business days prior to your appointment.

These appointments are scheduled for an hour in duration, but please plan to be here for approximately up to two hours.  The initial visit requires questionnaires, checklists, and summaries that need to be completed by the  parental guardian.  These forms can be sent to you by mail, or you can download them here on our website below. If you are not sure which forms to use, or have questions about the forms, please call us at 508-854-1380 on Monday, Wednesday or Thursday.

Please do not put a social security number on any of our forms. If one of our forms still asks for that, leave the field blank. Your privacy is very important to us. We do not collect social security numbers, in order to further protect your privacy.

Please print each item indicated, and complete and return them to our office as soon as possible. Do not use email to return these forms. Email is not secure, and your privacy is very important to us.  

Please do not bend the left edge of these forms, since they will be passed through a copy machine. The originals will be returned to you, so you can start your own health file at home.

The forms that are appropriate for you need to be completed in full and returned to our office for receipt BEFORE your appointment.  We highly recommend that you have these documents returned to the office AT LEAST ONE WEEK prior to your visit.  Please note, if you send your information in advance, you will have a much better experience, since our physician will become familiar with your child's case in advance.  For more information, or if you have questions, please contact our office and we will be happy to assist you.
 
FORMS

To download the forms required for your initial visit, you will be clicking on selected links below. These forms are stored as Adobe pdf files (portable document form files). You will need the free Adobe Reader program in order to view them. Most computers have this already installed.  If you do not have this program, you may obtain it by clicking on this link to the Adobe website:  https://get.adobe.com/reader/



For all patients, these forms are required:

Patient Registration
 
Authorization

Food Frequency Questionnaire (Pediatric)
(for patients 15 years old and younger)

Chronological Summary for Children
(for patients 15 years old and younger)


IF
the patient's symptoms vary from day to day or week to week or month to month,
THEN you should also fill out
this form:


Pediatric Allergy Database & Health History
(for patients 15 years old and younger)

Please use blue or black ink, PRINT each item indicated, and complete and return the forms to our office as soon as possible. These forms will be scanned into our computer and then returned to you.

Reminder:  Do not use email to return these forms, it is not secure.  



We are a fragrance free office. Click here for more details about that, and to read our cancellation and privacy policies.

Otherwise, use the menu system at the top of the page to navigate our website.



We provide integrative, functional medicine in Central Massachusetts in the Worcester area. Many of our patients come from Boston and the Metrowest Boston area as well as all areas of Massachusetts and the other New England states.

(C) Copyright 2013 and 2016 Francis Holistic Medical Center, Last Modified: April 17, 2017 at 3:47 pm EST