Acupuncture Intake Form
Name:
Date of Birth:
Emergency Contact:
Emergency Phone:
Emergency Relationship:
Please list your main complaint and Including when the issue started:
Please rate the intensity of your main complaint issue on a scale of 0-10: (10 is worst)
Please list any other complaints that are less immediate:
Please rate the intensity on a scale of 0-10: (10 is worst)
If there is pain, is it (check all that apply)
Dull
Sharp
Tight,
Tingling
does it move
does it radiate to another place in the body?
Medications
List Prescription Medications/Supplements/Herbs:
Medical History
Please list all major traumas/accidents/ Diagnosed illnesses (ex, Surgeries, Diabetes, Cancer, High Blood Pressure)
Please include any hardware present from surgeries.
Please list any major Illness/ injuries experienced in childhood
Please list any allergies
Any Major Illnesses in Family History
Check the following that apply
Do you have a pacemaker? *
Are you pregnant or could be pregnant?
Any communicable diseases such as MRSA, HIV, Hepatitis A, B, C, D or E TB or other?
Frequent sore throats
Previous Concussion?
Reproductive imbalances (Male or female)
Frequent Headaches?
Please elaborate any more information available about any checkmarks below. (including intensity, when it happens, what makes it worse, what makes it better, etc...)
Check if you have any of the following:
Heart palpitations?
Clotting or bleeding issues?
Anemia
Low Blood pressure
High Blood Pressure
Please elaborate any more information available about any checkmarks below:
Check if any of the following apply to you:
Easily Agitated
Depression
Anxiety
Grieving
Low Self Esteem
Low Motivation
(Please describe any check marks below) (ex. When, how often, scale of 1-10 in intensity) (10 is worst)
Check if any of the following apply to you:
Constipation
Diarrhea
Morning Diarrhea
Stomach pain
Frequent Urination
Discoloration
Please elaborate any more information available about any checkmarks below
Menstrual (if applicable)
Length of cycle,
Duration,
Cramping
Scale of 1-10 (10 is worst)
Sleep quality:
Digestion quality:
Eye health:
Ear health:
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 indicated 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 and in writing. The herbs may have 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 needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. 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.
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.
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. 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 with a Licensed Practitioner at Boulder Therapeutics, Inc.
Sign:
Colorado State Disclosure
Education & Experience
Bryan Rodriguez is a four-year (3000 hours) M.S. in Oriental Medicine from the Southwest Acupuncture College, Boulder Campus. He is certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) and is a licensed acupuncturist (Lic. #025260) in the State of Colorado; he has never had a license, certificate, or registration suspended or revoked. Mr. Rodriguez is trained and experienced in the recommendation and application of adjunctive therapies such as tui na & shiatsu (deep tissue and sports massage of Asia), manual therapy, recommendation of therapeutic exercise and the use of herbal poultices. He is also a trained Chinese herbalist. All of these adjunctive therapies fall under the definition of traditional oriental medicine.
Chris Chapleau, DLac, LAc , LAc, Dipl Ac, AIT, IMT, MSHP, CES, HMS Dr. Christopher Chapleau earned his Master of Acupuncture Medicine degree from the New York College of Health Professions in 2001. New York College of Health Profession’s Graduate School of Oriental Medicine consists of a 145-credit, nine-trimester, Acupuncture Program. Chris graduated with a Bachelor of Professional Studies in Health Science and a Master of Science degree in Acupuncture. This Acupuncture program is approved by the NY State Education Department and is accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), the recognized accrediting agency for the approval of programs preparing Acupuncture practitioners. This three to four-year program consists of 3,030 hours of education. The program includes 885 supervised hours of acupuncture training in their Academic Health Care Teaching Clinic. Chris was certified as a Diplomate in Acupuncture by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in 2001. Chris possesses his Doctorate in Acupuncture, awarded in 2019 from the Pacific College of Health Science. He has additional degrees in Exercise. Dr. Chris holds a Master of Science degree in Human Performance from Southern CT State University. He's certified as a Corrective Exercise Specialist from the National Academy of Sports Medicine, certified as an Integrative Manual Therapist and Human Movement Specialist through the Brookbush Institute, and has certifications in Functional Movement Screening I&II and Selective Movement Assessment I&II. Dr. Chris also holds various certifications in acupuncture medicine including Orthopedic & Sports Acupuncture, Acupuncture Injection Therapy, Facial Rejuvenation, NADA (community trauma), and Battlefield Acupuncture
Matthew Hudgens,Lac, LMT earned his Master of Acupuncture degree from the Institute of Taoist Education and Acupuncture (ITEA) in September of 2016. The four-year program consisted of 2445 hours of education and over 800 clinical practice hours. He received his certification of “Diplomat of Acupuncture” from the National Certification Commission for Acupuncture and Oriental Medicine in October of 2016. This included a certification in Clean Needle Technique. Matt is a member of the Acupuncture Association of Colorado. He is a certified massage therapist, and has held a license in Colorado since 2009. He graduated from the University of New Hampshire in 2006 with a BA in Psychology. Training and experience in the recommendation and application of adjunctive therapies and herbs is defined by traditional oriental medical concepts. None of these Certifications or Licenses have ever been suspended or revoked.
This clinic complies with all rules and regulations promulgated by the Colorado Department of Public Health and Environment, including those related to the proper cleaning and sterilization of needles used in the practice of acupuncture and the sanitation of acupuncture offices.
The practice of acupuncture is regulated by the Colorado Department of Regulatory Agencies. The Director’s address and telephone number is:
Director of Professions and Occupations Acupuncturist Licensure 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800
You are entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. Acupuncture treatment denotes a professional relationship, sexual intimacy is never appropriate and should be immediately reported to the Director of the Division of Professions and Occupations in the Department of Regulatory Agencies.
My training and experience in the recommendation and application of adjunctive therapies and herbs is defined by traditional oriental medical concepts.
Sign:
Surprise/Balance Billing Disclosure Form
Surprise Billing – Know Your Rights
Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:
· You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
· You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado
What is surprise/balance billing, and when does it happen?
If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.
You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Additional Protections
· Your insurer will pay out-of-network providers and facilities directly.
· Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
· Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
· No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.
If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint.
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.
Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.
I am aware that Boulder Therapeutics, Inc is NOT in my health insurance’s network, including all subcontractors and all services proivded. I am voluntarily procuring their medical services with this knowledge. I understand that Boulder Therapeutics, Inc will not bill my claim(s) to my health insurance for processing. By signing, I acknowledge that I am aware that Boulder Therapeutics, Inc is out of network with ALL health insurance and that I am voluntarily receiving services with full knowledge that they are out-of-network.
Client or Parent/Guardian Signature:
(If a minor, please have your Parent or Legal Guardian sign)
Consent for Purposes of Treatment, Payment and Health Care Operation
I consent to the use or disclosure of my identifiable health information by Boulder Therapeutics, Inc 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 at Boulder Therapeutics, Inc. may be conditioned upon my consent as evidenced by my signature on this document.
I have the right to revoke this consent, in writing, at any time except to the extent that Boulder Therapeutics,Inc has taken action in reliance on this consent.
My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review Boulder Therapeutics, Inc’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health information that will occur in my treatment.
Boulder Therapeutics, Inc reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office visit.
I understand that this clinic has a 24-hour cancellation policy and I will be liable for full payment for any appointments cancelled after this time. By signing below, I also authorize all employees and subcontractors of Boulder Therapeutics, Inc. to discuss and correspond about my medical status as it pertains to providing me with safe and effective massage therapy. I also understand that Boulder Therapeutics, Inc. operates within other medical and health facilities and those entities and their staff may have access to my information.