NEW PATIENT INTAKE FORM
I acknowledge that Modern Acupuncture seeks to provide the highest level of acupuncture care by only employing acupuncturists who are licensed and have graduated from accredited Master’s level programs consisting of at least 2,000 clock hours of combined instruction and clinical practice. Additionally they are required to pass rigorous board exams and meet state specific licensing requirements.
YES I ACKNOWLEDGE
Have you received acupuncture treatments before?
PATIENT INFORMATION
Name:
Gender:
Date of Birth:
Age:
Email Address:
Mobile:
Home Address:
,
Height: (format example: 5'10'')
Weight: (lbs.)
Patient Occupation:
Emergency Contact Name:
Emergency Contact Phone:
I authorize Modern Acupuncture to share my health and financial information with the contact below (leave blank if no one):
Name:
Phone:
I understand that occasionally, there could be minor bruising where the needles are inserted. To keep this to a minimum, Modern Acupuncture uses the highest quality needles available, which also provide the most comfortable treatment with virtually no pain.
*Initials Here
MEDICAL HISTORY
Are you currently taking blood thinners or on an aspirin regimen?
YES NO
Are you currently pregnant or trying to conceive?
YES NO
Do you have a seizure disorder?
YES NO
Do you have HIV/AIDs? (*answer not required)
YES NO
Do you have Hepatitis B or C?
YES NO
Do you have a known nickel allergy?
YES NO
Do you have any other contagious diseases?
YES NO
If you answered yes to the above, please list here:
What is your primary reason for visiting today? (select only 1, *required)
If you selected "Other" please list below:
Select the number that describes how severe your symptoms are:
How long have you been experiencing symptoms?
What aggravates your condition? (select all that apply)
Eating
Heat
Icing
Massage
Resting
Sitting
Sleep
Standing
Stress
Walking
Working
Other (please specify below)
If you selected "Other" please list below:
What relieves your condition? (select all that apply)
Heat
Icing
Massage
Resting
Sitting
Sleep
Standing
Walking
Other (please specify below)
If you selected "Other" please list below:
How motivated are you to improving this condition?
Are there any other conditions we may be able to address today?(select all that apply)
Allergies
Anxiety
Arthritis
Back Pain
Depression
Digestive issues
Fatigue
Fertility
Headaches
High Blood Pressure
Insomnia
Joint Pain
Knee Pain
Menstrual Cramps/PMS
Muscle Aches
Muscle Sprain or Strain
Neck Pain
PTSD
Stress
Vertigo
Other (please specify below)
If you selected "Other" please list below:
GENERAL HEALTH CONDITIONS
What is your stress level? (0 = None, 10 = Severe)
What is your overall energy level? (0 = None, 10 = Severe)
How would you rate your sleep quality? (0 = None, 10 = Severe)
Please select all medications and supplements you are currently taking:
Blood Thinners (ex. Coumadin, Warfarin)
Blood Pressure Medications
Pain Medications
Benzodiazepine / Sedatives
Epilepsy / Seizure Medications
Other (please specify below)
If you selected "Other" please list below:
FACIAL ACUPUNCTURE
If you are here for Facial Acupuncture, please complete the following questions:
Have you received Botox or dermal filler injections in the last 2 weeks?
YES NO
Have you had any cosmetic surgical procedures within the last 6 weeks?
YES NO
Do you have a tendency to bruise easily?
YES NO
Do you get migraine headaches once per month or more?
YES NO
Have you had a recent head injury or concussion?
YES NO
Facial visits include targeted areas of treatment on the face. Please select up to two areas you would like to focus on:
Crows Feet
Forehead lines
Lines between eyebrows
Lines surrounding lips
Marionette Lines (Sides of chin to edges of the mouth)
Smile lines
CONFIRMATION OF EVALUATION
In the State of Texas, Acupuncture and Oriental Medicine is not considered “primary health care”. As a result, Modern Acupuncture is required to have you respond affirmatively to the following statements before you may be treated, pursuant to the requirements of 22 TAC § 183.10(a)(11) of the Texas State Board of Acupuncture Examiners’ rules and section 205.302 V.A.C.S article 4495b of the Texas Medical Practice Act, governing the practice of acupuncture.
Licensed Acupuncturists are permitted to treat conditions of chronic pain, smoking addiction, substance abuse, alcoholism, and weight loss without a referral or prior evaluation by a physician. If you are seeking treatment for one of these conditions, please indicate which one below.
Chronic pain
Alcoholism
Weight loss
Smoking addiction
Substance abuse
If you wish to be seen for any other condition outside of those listed above, then please read the information below and select YES to at least one of the following statements. Please note that you will not be able to be treated today if your answer to either statement is NO.
I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 6 months prior to acupuncture begin performed.
YES NO
I have received a referral from my doctor or chiropractor within the last 30 days for acupuncture. The date of the referral is , and the most recent date of treatment prior to acupuncture is . After being referred by a doctor or chiropractor, if after 120 days or 30 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice whether to follow this advice.
NOTICE OF PRIVACY PRACTICES
Click below to read this office’s Notice of Privacy Practices.
HIPAA ACKNOWLEDGMENT - (Link will take you to a new browser window. Close or return to this page when done reviewing.)
By signing this I am acknowledging that I have had full opportunity to read and consider the contents of this office’s Privacy Practices, which can be found at modacu.com/privacy. I further acknowledge and understand that, by signing this Patient Intake Form that I am giving my consent for this office’s use and disclosure of my protected health information to carry out treatment, payment activities and health care options, as outlined in the Notice of Privacy Practices disclosure in the link above.
YES I ACKNOWLEDGE
If this acknowledgment is signed by a guardian (for a minor) or a personal representative on behalf of the patient please complete the following
INFORMED CONSENT FOR ACUPUNCTURE
This Informed Consent applies to the health and facial acupuncture. This consent will allow us to provide acupuncture treatments to you (or your dependents) now and in the future.
INTRODUCTION - An acupuncture treatment involves the insertion of acupuncture needles at specific points on your body to boost your body’s natural painkillers, increase blood flow and trigger a healing response.
A facial acupuncture treatment involves the insertion of acupuncture needles into fine lines and wrinkles on the face and neck in order to reduce the visible signs of aging. A facial acupuncture treatment addresses the entire body constitutionally, and is not merely “cosmetic.” A facial acupuncture treatment involves the patient in an organic, gradual process, that is customized for each individual. It is no way analogous to, or a substitute for, a surgical “face lift”.
BENEFITS - Facial acupuncture can increase facial tone, decrease puffiness around the eyes, as well as bring more firmness to sagging skin, enhance the radiance of the complexion, and flesh out sunken areas. Customarily, fine wrinkles will disappear, and deeper ones will be reduced. As this treatment is not merely confined to the face, but incorporates the entire body and constitutional issues of health.
ADDITIONAL CARE NECESSARY - Acupuncture should be relaxing and you will often feel very calm after a treatment. You may feel a little tired or sleepy and should take this into account if you are planning to drive or use heavy machinery straight after your treatment. You should refrain from vigorous exercise after treatment and, ideally, give yourself a little time to rest. It is also advisable not to drink alcohol for several hours after treatment.
RISKS OF ACUPUNCTURE - I understand that methods of treatment are limited to acupuncture. 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 dizziness or fainting. 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. While this document describes the major risks of treatment, other side effects and risks may occur.
Acupuncture, has very few side effects and any that do occur are usually mild and self-correcting. Possible side effects and complications may include the following: SORENESS: After acupuncture, you might have soreness, minor bleeding or bruising at the needle sites. BLEEDING: It is possible, though very unusual, that you may have problems with bleeding during an acupuncture treatment. Should post-acupuncture bleeding occur, it will usually only consist of a few drops. Accumulations of blood under the skin may cause a bruise, or hematoma, which will resolve itself. INFECTION: Infection is very unusual after an acupuncture treatment. Should an infection occur, additional treatment, including antibiotics, may be necessary. NEEDLE SHOCK: Needle shock is a rare complication after an acupuncture treatment. ALLERGIC REACTIONS: In rare cases, an allergic reaction to the metal needle may require additional treatment. DELAYED HEALING: Delayed wound healing or wound disruption are a rare complication experienced by patients in the aftermath of an acupuncture treatment. There is a greater risk for smokers, who frequently have dry, sagging skin, which does not heal as readily as that of non-smokers.
There are many variable conditions in addition to risk and potential complications that may influence the long term result from facial acupuncture treatments. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with an facial acupuncture treatment. Other complications and risks can occur but are even more uncommon. Should complications occur, other treatments may be necessary. The practice of acupuncture is not an exact science. Although good results are expected, there is no guarantee or warranty, either expressed or implied, on the results that may be obtained. DAMAGE TO DEEPER STRUCTURES: Deeper structures such as blood vessels and muscles are rarely damaged during the course of a facial acupuncture treatment. If this does occur, the injury may be temporary or permanent. ASYMMETRY: The human face is normally asymmetrical. Thus, there can be a variation from one side to the other in the results attained from a facial acupuncture treatment. BRUISING AND PUFFINESS: There is a possibility of bruising (hematomas), puffiness, blood, tingling, itching, warmth, pain or other symptoms at the site of the needle. NERVE INJURY: Injuries to the motor or sensory nerves rarely result from facial acupuncture treatments. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to sensory nerves of the face, neck and ear regions may cause temporary or more rarely permanent numbness. Painful nerve scarring is very rare. UNSATISFACTORY RESULT: There is the possibility of a poor result from an acupuncture facial. You may be disappointed with the results. LONG TERM EFFECTS: Subsequent alterations in facial appearance may occur as the result of the normal process of aging, weight loss or gain, sun exposure, or other circumstances not related to facial acupuncture treatment. A facial acupuncture treatment does not arrest the aging process or produce permanent tightening of the face and neck. Future facial acupuncture maintenance treatments, or other treatments, may be necessary to maintain the results of an acupuncture facial.
OPEN SETTING, COMMUNICATIONS & RECORDING DEVICES - All of your services will be provided in an open room setting where other patients are also receiving care. Other patients may overhear some of your protected medical information during the course of care. To the extent permitted by law, we may use cameras or other recording devices in a clinic. A notice will be posted at the clinic informing you of the use of such devices.
We reserve the right to refuse treatment to anyone who looks or acts as though they are under the influence of alcohol or drugs, cause a scene or make it impossible for other patients to enjoy their experience, or can be considered a threat to the health and safety of employees or patients.
Our clinics use curated music with the intent of enhancing your experience; however,. We make no claims, representations, or guarantees that the music component provides a physical or therapeutic benefit. In the unlikely event that you experience any unusual physical or mental discomfort please notify your acupuncturist to immediately. By being a participant of the music component in connection with the acupuncture services, you represent and warrant that you are in adequate physical and mental health to listen to such music and have no disability or condition that would make such listening detrimental for you.
UNDER NO CIRCUMSTANCES WILL MODERN ACUPUNCTURE OR ITS MUSIC LICENSOR BE LIABLE TO YOU FOR ANY LOSS OR DAMAGES OF ANY KIND (INCLUDING, WITHOUT LIMITATION, FOR ANY DIRECT, INDIRECT, ECONOMIC, EXEMPLARY, SPECIAL, PUNITIVE, INCIDENTAL OR CONSEQUENTIAL LOSSES OR DAMAGES) ARISING OUT OF OR RELATING IN ANY WAY, DIRECTLY OR INDIRECTLY, TO THE USE OF THE MUSIC COMPONENT.
METHODS OF CONTACTING YOU - We may use your address, phone number, e-mail and clinical records to contact you with notifications, text messages, birthday and holiday related messages, health related information, or other topics as appropriate, based on the contact information you provided above. If contacting you by phone, we may leave a message on your answering machine or voicemail. You may still receive our services if you do not provide a phone number or email address.
MISSED APPOINTMENTS - Please understand that appointment times are limited. If you must cancel your appointment, we respectfully request 12-hour notice. Missed appointments, or appointments canceled without 12-hour notice, will incur a fee.
DISCLAIMER - Informed-consent documents are used to communicate information about the proposed procedure along with disclosure of risks. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your acupuncturists may provide you with additional or different information which is based upon all the facts in your particular case and the present state of knowledge within the field of acupuncture. Informed consent documents are not intended to define or serve as the standard of acupuncture. Standards of acupuncture are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the following consent.
CONSENT FOR ACUPUNCTURE TREATMENT
1. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
2. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
- THE ABOVE TREATMENT OR EXPOSURE TO BE UNDERTAKEN
- THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED
3. 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 licensed acupuncturists practicing in the Modern Acupuncture clinic, including those who now or in the future work at any Modern Acupuncture clinic
4. If applicable, I WILL NOTIFY A CLINICAL STAFF MEMBER WHO IS CARING FOR ME IF I AM OR BECOME PREGNANT.
5. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, 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.
6. I understand that results are not guaranteed. I further 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 have had an opportunity to ask questions. Additionally, I affirm that I understand and agree to all the terms and conditions mentioned above. I also affirm that all of my information listed in this form is accurate and correct to the best of my knowledge.
*Initials Here
Modern Acupuncture complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Practice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
ARBITRATION AGREEMENT
By signing an arbitration agreement, a patient and a healthcare practitioner agree to use a private, confidential, and expedited arbitration, rather than a public, lengthy and costly courtroom trial, to settle any future malpractice claims. In arbitration, a neutral arbitrator (quite often a retired judge) decides the case. By agreeing to arbitrate, the parties preserve their right to present their claims fully; however, they choose a specific forum for dispute resolution: an arbitration hearing rather than a judge or jury trial.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, including whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. An acupuncture treatment involves the insertion of acupuncture needles at specific points on your body to boost your body's natural painkillers, increase blood flow and trigger a healing response.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by la, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.
Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. I understand that methods of treatment are limited to acupuncture. 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 dizziness or fainting. 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. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. *Initials Here
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I hereby authorize White Tiger MA, LLC to render medical services to me and to release any information regarding my medical history, diagnosis and treatment of myself to my insurance company regarding my claim for acupuncture benefits and to the referring physician. I authorize payment of medical benefits to this practice for services rendered to me. *Initials Here
This clinic is owned and operated by White Tiger MA, LLC
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