Acupuncture Consent Acupuncture / Traditional Chinese Medicine
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- Opal Neal
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1 Personal Information Last Name First Name Initial Date of Birth Age: Address City Sex Province Postal Code Home No. Work No. Cell No. M F Primary care (medical physician) Occupation Employer How did you hear about Jasmine? Reason For Your Visit What is your complaint? How long has it been? Is your condition related to an auto accident or job related injury? Y N Have you been treated by any other doctor for this complaint? If yes, by whom: Y N What type of treatment was rendered? Chiropractic Medication Physiotherapy Massage Steroids/Cortisone Injections Other: Have you ever had this, or a similar condition before? If yes, what did you do to relieve this problem? Y N Have you had any of the following tests for your current complaint(s)? Blood test X-rays MRI CT Name of doctor and/or office that ordered your test(s) and the approximate date: Over
2 Appointments Appointment frequency and expected duration should be discussed with the doctor and scheduled appropriately with the receptionist. Please check in at reception each visit. It is important that you arrive a few minutes before each treatment time, in order to prepare. Cancellations, Lateness and No-shows If you need to cancel, informing us of your changed schedule as early as possible is appreciated. Any appointment cancelled with less than 24 hours notice, or no-shows, will be charged the full treatment fee (which may not be covered by your Extended Health Care Plan). This is necessary to ensure proper respect for treatment times and the difficulty in re-scheduling with less than 24 hours notice. Payment Extended Health Care benefits vary depending on your insurance policy. Clients are responsible for full payment of their account at the end of each visit. Payment can be made by cash, debit or credit card. Treatment Fees Initial assessment and acupuncture treatment (60 minutes) $ HST Basic acupuncture (30 minutes) $ HST Extended Acupuncture (45 minutes) $ HST Facial Acupuncture (60 minutes) $ HST Relaxation Acupressure (Head, Face and Neck 30 minutes) $ HST (not covered by insurance) Personal Belongings The clinic cannot be held responsible for loss or damage to personal belongings. Bring your belongings into the treatment with you in order to avoid the risk of loss. Thank you for your co-operation in the above matters. I would like to receive clinic newsletters and case studies by . Yes No Informed Consent to Assessment and Treatment I hereby request and consent to the performance of physical assessment/ treatment procedures on me by the Traditional Chinese Medicine Practitioner. My consent is voluntary and I intend this consent form to cover the entire course of assessment/ treatment for my present condition, commencing on the date indicated below. I understand that I may ask questions at any time regarding: What the assessment/ treatment is Who will be performing the assessment/ treatment The reasons why I should have the assessment/ treatment The alternatives to having the assessment/ treatment What potential risks and/ or side effects exist for the proposed assessment/ treatment I understand that this consent may be withdrawn, in writing, at any time, except for actions already taken. I hereby request and consent to receive traditional Chinese medical treatments including acupuncture, herbal medicine, Tuina massage, and other related treatments. I acknowledge that the above treatment and all its ramifications have been fully explained to me. I also absolve the clinic and its practitioners if I experience from any unexpected results of the treatment. I further agree to not commence lawsuit of any kind against all parties mentioned. Patient Signature Printed Name Date
3 Consent to Acupuncture This statement of consent pertains to the activities of a qualified registered acupuncturist. I, acknowledge that acupuncture is helping me through the use of sterile acupuncture needles. I understand that there is a possibility of bruising or minor bleeding throughout the treatment. I understand that Herbal Therapy includes the use of herbal extracts or raw herbs, and I will not hold you accountable for prescribing. I understand that there is a possibility of minor discomforts such as abdominal upset, diarrhea, or insomnia as the reaction to the herbal therapy. I understand that acupuncture and herbal therapy are not intended to take place of medical care or medications. I understand that acupuncture or herbal therapy cannot predict the actual outcome or how long the effects will last. I understand that I can discontinue my treatments at any time. I will keep the acupuncturist updated on my physical condition. Please read the following and sign below: TCM (Traditional Chinese Medicine) modalities (acupuncture, herbal medicine, cupping, Tuina massage, etc.) are safe and effective for the prevention and treatment of a wide range of health conditions and for the promotion of general well-being. Although Acupuncture/TCM are helpful for many health conditions, it is not intended to replace any tests or treatments recommended by your physicians. Please continue your medications prescribed by your physician while you receive TCM services at this clinic. TCM treatments are not covered by OHIP. Coverage is provided by some extended healthcare plans, thus you are kindly advised to check with your private insurance plan or employee benefits. The cost please refers to the fee list. Payment can be made with cash or cheque. A $25 NSF fee will be applied to any returned cheque. No refund for any purchase. TCM treatments are generally safe and effective. Occasional bruising, post needling sensation, or fainting may occur for some patients due to nervousness, hunger, or extreme tiredness. Occasional abdominal upset, cramping, diarrhea, insomnia, sweating, allergy or other symptoms may happen when taking herbal medicine although this can be the response of the body to the treatment. If you have any concerns please do not hesitate to ask. Facial Acupuncture Only I understand that I do not have any of the contraindications for Facial Acupuncture mentioned below: Heart disease Pacemaker Problems with bleeding or bruising Pregnancy High blood pressure Diabetes Former plastic surgery Severe migraine Herpes Patient Signature Date
4 Lifestyle (Diet, Exercise, Stress, Smoke, Drink, Other Substance Use) Significant Illness, Disorders and Trauma Respiratory & Chest Current Medications Appetite, Bowel Movement & Condition of Abdomen Pain and Numbness (Location, Duration, & Characteristics) Urination & Libido Sleep Gynecology Age of Menses Began: Age of Menopause: Menstrual Cycle: Duration of Flow: Color & Amount of Flow: PMS: Vaginal Discharge & Color: Vaginal Sores & Odor: # of Pregnancies: # of Live Birth: # of Premature Birth: Miscarriage, Abortion: Date of Last PAP: Date of Last Period: Energy Emotions Family History Tongue and Pulse Head, Face, & Neck General Appearance, Smelling & Listening Body Temperature, Sweating & Skin
5 Differentiation Treatment Principles Treatment Remedies
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Stanislaw Facial Plastic Surgery Center LLC Paul Stanislaw Jr., M.D.
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Fax or mail records to: San Diego Center for GYN Oncology. 955 Boardwalk St. Sui Murrieta Ca 92562 San Marcos Ca 92078 Fax: 760 471-0211
1. Thank you for choosing San Diego Center for GYN Oncology for your care. This packet contains information you will need for your appointment. Please review this information closely and contact our office
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
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Holistic Chiropractic and Craniosacral Therapy. Rosewood Family Healing Center - Dr. Maura Moynihan
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How To Get A Free Acupuncture Session
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EXCEL PHYSICAL THERAPY, INC.
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Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
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