Dr. Rima network Questionnaire

Dr. Rima Network
Private and Confidential Questionnaire.

This questionnaire is for private persons who wish to engage in a private discussion with Dr. Rima regarding their own (or child's) wellness concerns. Submitting this Questionnaire does not create a doctor/patient relationship and is for wellness consulting only. Dr. Rima E. Laibow MD charges an hourly fee for her time and advice.

Full name:
Home Town, State:
E-Mailing address:
Phone number:

1. Please summarize your reason(s) for setting up a consultation with Dr. Rima, briefly. Is this consultation for yourself? If not, please give us your relationship to the person for whom the consultation will be held, include gender and date of birth.


2. What would you like this consultation to accomplish? Please specify the letter of as many as apply - (a) Second Opinion; (b) Finding other options to deal with a disease or condition; (c) General information; (d) Product information; (e) Laboratory test data review; (f) Other (please specify).


3. Please tell me a bit about your past medical and psychological history, or, if the consultation is for another person, about their history.


4. What medications or nutrients are you using? Please give generic names if you are taking pharmaceuticals, dose and number of times per day. Please remember to list ALL the herbs, nutrients and supplements you are taking on a regular basis.


5. Please use this space for more details about your condition.


6. Contact Preferences? Please state: Contact me (a) morning after ___ AM; afternoon between ___ and ___ PM; evening between ___ and ___ PM. (b) Select one: Only on weekdays; Only on weekends; Any day of the week. (c) I am located in (Country) and my time zone is: _____. (d) Select one: You may leave a message; do not leave a message. (e) Contact me using (i) email only; (ii) phone only or (iii) either.


7. I would like Dr. Rima to review the following relevant medical documents Please list each document or indicate the number of documents of each type to be reviewed. Include all lab work, and other documents you would like Dr. Rima to review. Medical Documents will be accepted as scans or email attachments only. Originals and hard copies will not be accepted unless special arrangements are made. You will be notified of the amount of time estimated for Dr. Rima to review these tests and will be billed for that time before the consultation takes place.


Scheduling a Consultation:

Your consultation(s) with Dr. Rima will be scheduled after your credit card payment has cleared. You will be notified by our Administrator to set up your appointment time. You will be given a phone number that you can call for the consultation. All consultations are by pre-paid appointment only.

Dr. Rima has severely limited time available for clinical consultations. Your consultation time belongs to you, but unused time for consultations which begin late, terminate early or are missed for reasons other than a life-threatening emergency will not be refunded although you may schedule another appointment for an additional fee.

Suggested Donation for Dr. Rima's Services:

  • Review of laboratory and other clinical data: $35 per 15 minutes or fraction thereof

  • Initial Consultation: $300 per hour or fraction thereof, pro rated at $75 for each 15 minutes or fraction thereof

  • Followup Consultations: $250 per hour or fraction thereof, pro rated at $62.50 for each 15 minutes or fraction thereof

  • Written report of Consultation: $250 per hour or fraction thereof, pro rated at $62.50 for each 15 minutes or fraction thereof

  • Written Clinical Opinion letter or report: $250 per hour or fraction thereof, pro rated at $62.50 for each 15 minutes or fraction thereof


Note: Dr. Rima's services are based on her extensive clinical experience practicing -free psychiatry and medicine for nearly 40 years. She is heavily occupied with health freedom issues (see www.GlobalHealthFreedom.org) and with the creation of the Valley of the Moon(TM) Eco Demonstration Project, www.NaturalSolutionsFoundation.org in Panama so, currently, Dr. Rima cannot undertake the direct treatment of patients.

In the near future, however, the opening of our Natural Solutions Center in Volcan, Panama, will make it possible to patients to travel there and receive outstanding health care under her personal supervision. Please email us at NSFmarketplace@gmail.com (with 'Dr. Rima's Center' in the subject line) if you'd like to be informed of the opening of the Center, expected during early Summer, 2010.

Your information is private and will not be shared with anyone. Ever. That is Dr. Rima's promise to you.

-