CONFIDENTIAL – NEW PATIENT

INFORMATION SHEET

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H&J Healing Clinic(HNJHC) does not disclose the protected health information and/ or sensitive health informaiton over phone, via electronic mail, or via written communication without patient written authorization. If we need to communicate about your procted health information, we will contact you to shedule a consultation

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Last name:_____________________________ First name:____________________ Middle name:___________________

Date:___________________________________________

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PATIENT INFORMATION

MEDICAL COMPLAINT

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Date of Birth:_____________________ Age:______ Gender: ! Fem"<$ ! Male

Height%&''''''''''' Weight:_________ &&:",/)"<&1)")E-% Single Married&

Smoking: Current Smoker Former Smoker Never Smoker Frequency:_______________&&

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Notice of Privacy Policy Our clinic is dedicated to providing service with respect for human dignity. Protecting your privacy and your healthcare information is fundamental in the course of our relationship. This notice will remain in effect until it is replaced or amended by changes in law. Information that we receive from you, other healthcare providers and/or third party payers is used for your treatment, payment of your bill and our healthcare operations. You may specifically authorize us to use protected health information or to disclose your health information by submitting the authorization in writing to us. We may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation, and/or your employer if required, or with other medical practitioners that you authorize. This clinic will not use your health information for marketing purposes without your written authorization. We may, however, send you birthday cards, newsletters and appointment reminders, by telephone or mail. Disclosure When required by law, this office may use or disclose your protected health information. Patient Rights 1. Upon written request you have the right to access, review or receive copies of your healthcare records. There is

a copy fee (minimum of $15 or legal amount) and 10 working days for us to process this request. 2. Upon written request, you have the right to receive a list of items this office disclosed about your healthcare

information. 3. You have the right to request that this office place additional restrictions on disclosure of your protected health

information. 4. You have the right to request in writing that we amend your protected health information. 5. You have a right to receive all notices in writing. If you have questions, complaints or want more information, please contact this office. You may send written complaints to the U.S. Department of Health and Human Services.

H&J Healing Climic 7139 E. Thunderbird Rd, Suite 2. Scottsdale, AZ 85254.

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Acknowledgement of Receipt of Notice of Privacy Practices

H&J Healing Clinic

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I, __________________________________, have received, read, reviewed, understand my rights and agree to the statement of the Privacy Policy for healthcare services in this clinic. By way of my signature below, I provide H&J Healing Clinic with my authorization and consent to use and disclose my protected health information for the purposes of treatment, payment and health care operations as described in the Privacy Notice. Patient Signature: ______________________________________

Date: ___________________

Patient Printed Name: ___________________________________

H&J Healing ClinicInformed Consent to Treatment

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By signing below, I do hereby voluntarily consent to be treated with acupuncture, Chinese herbs and Oriental medicine by a licensed acupuncturist at the H&J Healing Clinic. Acupressure/Tui-Na Massage: I understand that I may be given acupressure/tui-na massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment at any time. Electro-Acupuncture: I understand that I may be given electricity administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this or any treatment. Acupuncture/Moxibustion/Cupping: I understand that acupuncture is performed by the insertion of needles through the skin and moxibustion is performed by the application of heat to the skin at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, numbness or tingling, dizziness or fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. Bruising is a common side effect of cupping. Burns and/or scarring are a potential risk of moxibustion. I understand that no guarantees concerning these procedures are given to me and that I am free to stop these treatments at any time. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. Chinese Herbs: I understand that herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended to me are for the treatment of bodily dysfunction or diseases, to modify or prevent pain perception and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effects may result from taking these substances. These could include, but are not limited to: abdominal pain or discomfort, nausea, gas, stomachache, vomiting, headache, diarrhea or constipation, rashes and the possible aggravation of symptoms existing prior to herbal treatment. I understand that some herbs may be inappropriate during pregnancy. Should I experience any problems, which I associate with these substances, I should suspend taking them and call the H&J Healing Clinic as soon as possible. Pregnancy: I will notify the acupuncturist treating me if I am or I become pregnant. I do not expect the H&J Healing Clinic staff to be able to anticipate and explain all possible risks and complications of treatment. I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I understand that the medical and administrative staff may review my medical records and lab reports, but my records will be kept confidential and will not be released without my written consent (unless in an Emergency or by legal demand). I give my permission and consent to treatment.

Signature: ________________________________________________________

Date: ________________________

Printed Name: ____________________________________________________