Acupuncture New Patient Information

Date

Full Legal Name

Gender

M F

Date of Birth Age Marital Status

Single Married Separated Divorced

Address

City State Zip

Daytime Phone # (home, work, cell – circle one)

( )

Alternate Phone # (home, work, cell – circle one)

( )

Emergency Contact & Relationship

Phone Number of Emergency Contact

Primary ( ) Alternate ( )

Circle Health Insurance Coverage

None PPO POS HMO Workers’ Comp Auto Injury with MedPay Military Other

E-mail

___________________________________________________________________________

May our acupuncturist discuss your private medical information with you via e-mail? Yes / No * Please be aware that e-mail is not a secure communication and that discussion of your medical care will become part of your medical record.

Are you under the care of a physician? □ Yes

□ No

For what conditions?

Primary Care Doctor

Phone number Specialty

Other Doctors You See

Other Doctors You See

Name ________________________________

Date _______________________________

Acupuncture Consent Form

Please read and answer the following questions as accurately as possible.

1. Have you ever been exposed to Hepatitis? Yes No

2. Have you ever had any form of Hepatitis? Yes No

3. Have you ever been exposed to HIV (AIDS)? Yes No

4. Have you ever been exposed to any other blood borne disorders? Yes No

5. Do you have AIDS or HIV? Yes No

6. Do you take blood thinners or anticoagulants? Yes No

7. Do you take aspirin on a regular or frequent basis? Yes No

8. Do you take steroids on a regular or frequent basis? Yes No

9. Are you pregnant? Yes No

I do hereby authorize and direct Courtney Silke, D.C., L.Ac. to perform acupuncture and other forms of meridian

therapy. I understand that the nature of acupuncture procedures involves the insertion and retention of sterile

needles at one or more sites on my body. I have engaged in sufficient discussion of the treatment and possible

risks, alternatives, options and likely outcomes to satisfy my understanding of this form of treatment. I state

and agree that I understand acupuncture procedures sufficiently to give my informed consent to treatment.

Further, I state and agree that in no manner have I been promised a beneficial result from acupuncture

treatment or from any treatment at this time.

I have read and agree with the above statement, and consent to the use of acupuncture and meridian therapy

treatment in my care.

_____________________________________ ______________________

Patient or Guardian Signature Date

Consent to Share Confidential Medical Information

TO BE VALID, ALL LINES WITH AN ASTERIK (*) ON THIS FORM, MUST BE FILLED OUT COMPLETELY, including what information you are giving us permission to share. Place N/A on lines not applicable to your care.

*Patient’s Legal Name: _______________________________________ *DOB__________________ *I HEREBY AUTHORIZE VSC WELLNESS CENTER TO SHARE: 1. Any of my medical information, including information about my medical diagnoses and imaging results 2. My appointment times, dates, and reasons for the visits and/ or billing issues 3. The following information (specify): ________________________________________________ *WITH THE FOLLOWING PEOPLE: Full Name: __________________________________________________ Relationship: ___________________________

Authorized to share: 1 2 3 This authorization expires: Date: _________________ Full Name: __________________________________________________ Relationship: ___________________________

Authorized to share: 1 2 3 This authorization expires: Date: _________________

*I understand that my treatment, enrollment, or eligibility for benefits will not be conditioned on my signature ---------------------Initial______ *I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law ---------------------------------------------------------------------------------------------- Initial______ *I understand that I may cancel this consent at any time (by writing to VSC Wellness Center), but that canceling it will not affect any information that has already been released. I understand that I do not have to sign this form, and that I should only sign it if I want my provider or my clinic to share my information with someone. If no expiration date or event is specified, this authorization will expire one (1) year after the date it is signed. *Signature: ____________________________________________ Date: ___________________ *Relationship to minor patient (if parent or legal guardian) : __________________________________ If you are not the minor patient’s parent, you must give us proof of guardianship (for example, a court order or power of attorney) Witness: _____________________________________________ Date: ___________________

Acknowledgement of Policies and Procedures / Please Read and Sign

*Co-Pays are due at the time of service. Account balances must be below $150.00. ---------------------------------------------------------------------Initial______

*It is required that you arrive 10 minutes before your scheduled muscle therapy appointment. If you are not here at that time your appointment may be given to another patient. --------------------------------------------------------------------------------------------------------------------------------------Initial______

*We require a 24-hour notice to change or cancel appointment. A $25 fee for a 30 min appointment or a $30 fee for a 60 min appointment

will be charged if you cancel or miss a muscle therapy appointment with less than 24-hour notice. No-Show/less than 24-hour notice

more than 3 times will require prepayment at the time of scheduling for any future muscle therapy appointments. ---------------------------Initial______ *I have been given the opportunity to review the Financial Terms and Conditions -----------------------------------------------------------------------Initial______

HIP & MEDICAID PATIENTS: *If you miss three (3) scheduled muscle therapy appointments, you will not be able to schedule any muscle therapy appointments for a year. Any previously scheduled appointments will be cancelled after the third missed appointment---------------------------------------------------------Initial______

Acknowledgement of Privacy Policy

*Certain treatments may be performed in a common therapy area and/or you may find yourself within public areas within the clinic, but please note private rooms are always available, upon request, for discussing your private health information-------------------------------------------- Initial______ *This is to acknowledge that I have been given the opportunity to review VSC Wellness Center’s Notice of Privacy Practices. I acknowledge that I have read and understand the policies and procedures of VSC Wellness. I understand that I have the right to request a personal copy of this office’s Notice of Privacy Practice. *Sign ____________________________________________________________ *Date _____________________________

Form updated January 2020