Acupuncture Intake Form

INSURANCE INFORMATION

(Do not fill out if we have your information on file already)

Primary Insurance

Secondary Insurance

I understand that this is a quotation of benefits and is NOT a guarantee of payment, and the agreement is between the Insurance Carrier and me. I authorize any and all payment from my insurance carrier directly to this office with the understanding that all monies be credit to my account upon receipt. Any denial of payment becomes my responsibility (patient).

PRIMARY HEALTH CONCERNS 

(List in order of concern to you) 

Health Concern #1

Health Concern #2

Health Concern #3

Health Concern #4

Health Concern #5

LIST OF INJURIES

(falls, sports injuries, repetitive stress injuries, major traumas)

PERSONAL MEDICAL HISTORY

LIFESTYLE

NUTRITION

Woodinville Chiropractic

(please read, initial, & sign below)

OFFICE POLICIES

At Woodinville Chiropractic, we understand that life happens. If you need to reschedule an appointment please call or email us 24 hours in advance of the scheduled appointment time. We have a cancellation policy of $50 for any appointments cancelled or rescheduled within 24 hours. As a courtesy to your practitioner, please give advanced notice for rescheduling, as it is greatly appreciated.

CONSENT FOR RELEASE OF INFORMATION

Woodinville Chiropractic respects your privacy. We understand that your personal health information (PHI) is very sensitive. We will not disclose your information to others unless you allow us to do so, or unless the law authorizes us to do so.

Federal and state laws allow us to disclose your PHI for purposes of treatment and health care operations. State law requires us to get your written authorization to disclose this information for payment purposes.

I, authorize Woodinville Chiropractic:

FINANCIAL POLICIES & AGREEMENTS 

INSURANCE NON-COVERED SERVICE DISCLOSURE & AGREEMENT 

AUTHORIZATION FOR TAKING AND RETAINING X-RAY FILMS

I hereby authorize the taking of analytical x-ray films by the doctors, clinic, and/or staff of Woodinville Chiropractic, of such areas as may be of anatomical interest and which may be recommended from time to time by the doctor(s).

Further I agree that the doctor(s)/clinic shall be the sole owner of such analytical films and shall remain in custody and in control of said films, until such time as I shall sign a Release Form stating otherwise that will be provided by Woodinville Chiropractic upon request.

By signing below I, the patient, acknowledge that I have read the above statements regarding my care and treatment at Woodinville Chiropractic. This consent will remain in effect until revoked by me, the patient, in writing.

Acupuncture Informed Consent To Treat

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist named below 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 below, including those working at the clinic or office listed below 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, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling.

I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

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 needing sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping.

Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. 

Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses.

I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.

I understand the clinical and administrative staff 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.

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 .