Post on 30-Nov-2018
Name: Birth Date: / /
Street Address:
Mailing Address:
City: State: Zip: Sex: M F
Home Phone: ( ) Marital Status: Single Married Domestic Partnership
Work Phone: ( ) Occupation: Email:
In case of emergency, contact: Relationship:
Telephone: ( )
How did you hear about us?
Do you have insurance? Yes No HMO? Yes No Insurance Carrier: ________________________________
Policy No. ________________________________ Group No. __________________________________________
Are you being treated elewhere? Yes No Name of Personal Physician : ______________________________
Are you currently using prescription or herbal medicines? Yes No If yes, please list below:
PATIENT INFORMATION INTAKE FORMTo help us provide you with the best possible care, please !ll out this form as accurately as possible. All information
will be kept con!dential in your patient !le.
MEDICAL HISTORY: Please check the boxes below that are now or have been a part of your personal health history.
Arthritis Abortion Allergies (specify) ____________________Anemia Asthma Bleeding Tendency Blood Pressure - High Blood Pressure - Low Bronchitis Cancer
Chronic Fatigue Diabetes Digestive Disorders Emotional Disorders Emphysema Epilepsy Headaches Heart Disease Hepatitis (Specify Type) A ____ B ____C ___Heavy Bleeding
HIV+ Hypogycemia Injuries Insomnia Irregular Pregnancy Menstrual Irregularity Surgery Vaginal Infections Other
Current Past Current Past Current Past
PLEASE TURN OVER.. . . . .COMPLETE & SIGN THE OTHER SIDE
Marcia D. Connelly, L.Ac., Dipl.O.M.Licensed Acupuncturist & Herbalist
6892B Soquel AvenueSanta Cruz, CA 95062831-818-7051
LIFESTYLE: Which of the following is/are a part of your lifestyle?
Tobacco SmokingCo!ee DrinkingAlcohol Drinking
Recreational DrugsBirth Control PillsSoft Drinks / Soda
ExerciseRelaxation/MeditationVitamins/Supplements
PLEASE CIRCLE ANY AREAS OF PAIN OR INJURY:
Sudden Onset vs Gradual Onset Constant vs Intermittent Sharp vs Dull
Spasms/Tremors Sti!ness Numbness Tingling Swelling/Edema Burning Bruising/Tenderness Radiating to
OFFICE POLICY:All fees for medical services are due at the time of visit unless prior arrangements have been made in writing. Acceptable forms of payment are cash, check and credit card.
If you need to cancel or reschedule an appointment, please give a minimum of 24 hours notice. There may be a cancellation fee of $35 for less than 24 hour noti"cation unless otherwise speci"ed by Marcia D. Connelly, L.Ac., Dipl.OM.
Please indicate your understanding and acceptance of these policies by initialling here ________
I value the privacy of your health information. Please ask to review my health information privacy policy.
PATIENT SIGNATURE(Or Patient Representative) X
TOP FOUR MAJOR HEALTH CONCERNS: Please list in order of priority
Marcia D Connelly, LAc, Dipl.OM 6892B Soquel Avenue, Santa Cruz, CA 95062 mcherbgal@gmail.com 831-‐818-‐7051 Informed Consent Form I hereby request & consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or the patient named below, for whom I am legally responsible) by the acupuncturist named above and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named above, including those working at the clinic or office listed above, or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxabustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. The clinic uses sterile disposable needles and maintains a clean and safe environment. I have been informed that acupuncture is a generally safe method of treatment but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and less common side effects of dizziness or fainting. Bruising is a common side effect of cupping. I have been verbally informed by my practitioner of the known possible common and rare side effects and risks of acupuncture, moxa, cupping and herbal treatments. I understand that herbs (which are from mineral, plant or animal sources) prescribed may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify my practitioner of any unanticipated or unpleasant effects associated with the consumption of the herbal prescription. The herbs that have been recommended are traditionally considered safe in the practice of Chinese medicine. Some possible side effects of taking herbs are nausea, gas, stomachache, headache, diarrhea, rashes, and hives. I understand that herbal prescriptions and herbal patent medicines are intended only for the person for which they are prescribed and are not to be given to anyone else. I understand that some herbs may be inappropriate during pregnancy, and I will notify the acupuncturist if I am or become pregnant. If I am being treated for labor preparation I understand that this procedure, while traditionally practiced as part of Chinese Medicine, is not considered as a “medical induction of labor” as performed in a hospital setting. Labor preparation treatments are designed to relax the body and in doing so promote the most optimal conditions for labor to arise on its own. I specifically waive my right to any legal claim that may arise through labor preparation treatments. I agree to hold Marcia Connelly, L.Ac.,Dipl.OM harmless for any and all complications that may occur to me or my child as a result of acupuncture for labor preparation. I do not expect the practitioner to be able to anticipate and explain all the possible risks and complications of treatment, and I wish to rely on my practitioner to exercise judgment during the course of treatment which she thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand that my practitioner may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. I understand that if I am paying with insurance, there is no guarantee of benefits and payment by the insurance company, and that if it is decided by my insurance company that acupuncture is not a covered service, or if it is denied without an appeal or an unsuccessful appeal, I agree to pay out of pocket for my treatments. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Name (please print): Date: Patient Signature: Date: (Or Patient Representative; indicate relationship if signing for patient) Office Signature: Date: Form: 2017
Marcia D Connelly, LAc, Dipl.OM
Live Oak Acupuncture & Healing Arts
Our Privacy Policy
Dear Valued Patient, We do our best to protect your health information and privacy. This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.
Safeguards in place at our office include:
• Limited access to facilities where information is stored. • Policies and procedures for handling information. • Requirements for third parties to contractually comply with privacy laws. • All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on
permanent file.
Types of information that we gather and use:
In administering your health care, we gather and maintain information that may include non-‐public personal information.
• About your financial transactions with us (billing transactions). • From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone
conversations to or from other health care practitioners. • From health care providers, insurance companies, workman’s comp and your employer, and other
third part administrators (e.g. requests for medical records, claim payment information).
We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at (831) 818-‐7051.
Sincerely, Marcia Connelly, L.Ac., Dipl.OM Live Oak Acupuncture & Healing Arts, 6892B Soquel Ave, Santa Cruz, CA 95062 I consent to the use or disclosure of my identifiable health information by Marcia D. Connelly, L.Ac. (here after noted as Marcia) for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or treatment of me by Marcia may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Marcia is not required to agree to the restrictions that I may request. However, if Marcia agrees to a restriction that I request, the restriction is binding upon Marcia. __________________________________________________ _____________________ Signature of Patient or Authorized Representative Date
____________________________________________________________________________ Printed Name and Relationshi