1) Please fill out ALL New Patient forms in their entirety.

2) If you have any recent labs and images (within 12 months), please bring them to your appointment.

3) If you are married or in a relationship, please bring your spouse or significant other with you to your first appointment. (There will be much information covered concerning your unique condition as well as the fundamentals of the program

5) We require a 24-hour notice to change or cancel your appointment.

weMED Health Patient Information

What is your daily/weekly intake of the following:

I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health.

This notice summarizes how health data about you may be used and shared and how you can get access to this data. IMPORTANT NOTE: This does not include all of the details about our privacy policy. For more details, please read the NOTICE OF PRIVACY PRACTICES that your practitioner has provided you.

How we may use and share health data about you: a. Treatment – To give you medical treatment or other types of health services. b. Payment – To bill you or a third party for payment for services provided to you. c. Health Care Operations – For our own operations such as quality control, compliance monitoring, audit, etc. Disclosures where we do not have to give you a chance to agree or object: a. To you b. As required by federal, state, or local law c. If child abuse or neglect is suspected d. Public health risks (for public health activities to prevent and control spread of disease) e. Lawsuits and disputes (in response to a court or administrative order) f.Law enforcement (to help law enforcement officials respond to criminal activities) g. Coroners, medical examiners and funeral directors h. Organ or tissue donation facilities if you are an organ donor i.To avert a threat to an individual or to public health safety Disclosures where we have to give you a chance to agree or object: a. Patient directories – You can decide what health data, if any, you want to be listed in patient directories. b. Persons involved in your care or payment for your care – We may share your health data with a family member, a close friend, or other person you have named as being involved with your health care. Other uses of health data: Other uses not covered by this notice or the laws that apply to us will be made only with your written consent. You have the following rights relating to the health data we keep about you: a. Right to inspect your health recorded and to receive a copy of your health record upon request b. Right to amend information in your health record you believe is inaccurate or incomplete c. Right to know to whom we have disclosed your health information d. Right to ask for limits on the health information data we give out about you e. Right to receive communication form us about your health information in alternate ways f.Right to paper copy of the complete Notice of Privacy Practices

I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice.

weMED Health 4126 Southwest Fwy, #1130, Houston, TX 77027

I acknowledge that it is the policy of weMED Wellness to leave reminder messages on my answering machine or with another person in my home. I may make a request for an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Office Manager about my concerns.

We are compelled to re-institute our cancellation policy:

24 Hour cancellation policy for follow - up visits

48 Hour cancellation policy for new visits

A $50 fee will be assessed on your next invoice.

We understand that situations may happen. We will make every effort to accommodate re-scheduling in the event of an emergency.

(Pursuant to the requirements of 183.6(e) of this title (relating to Denial of License; Discipline of Licensee) and Tex. Occ. Code Ann., 205.351 governing the practice of Acupuncture

, am notifying the Acupuncturist

1.   I have been evaluated by a physician or dentist for the condition being treated within 12 months before the Acupuncture was performed, I recognize that I should be evaluated by a physician or dentist for the condition being treated by the Acupuncturist. 

2.  If applicable, I have received a referral from my chiropractor within the last 30 days for Acupuncture. 

After being referred by a 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 of whether to follow this advice.

Note: Exemptions according to Rule 183.6(e) Scope of Practice 3) am Acupuncturist holding a current and valid license may without evaluation or referral from a physician, dentist, or chiropractor perform Acupuncture on a person for smoking addiction, weight loss, alcoholism, chronic pain, or substance abuse.

By signing below, I acknowledge that weMED Health does not recommend or encourage patients to reduce or stop medications unless the patient has discussed this with the prescribing physician. It is the policy of weMED Health that all medication use be evaluated by a licensed medical professional acting within the scope of his or her practice.

1. I don’t have the personal knowledge to make the correct lifestyle choices.

You have the power to choose to learn. If you are open to learning, our personal mentoring program will guide you along an easy to follow path. Our programs are structured in a manner that gives each and every patient the information needed to bring independence to their life. You do have the choice to avoid the all too common dependency of a care

2. I don’t have the time to take appropriate care of myself.

We all live in a world that gives each of us 24 hours /day. What we do with that time is a personal decision based on values (real or perceived If you do not take time to care for yourself, you will have to take time to try and repair yourself. Pro-activity and maintenance are required for optimized health. It takes no more time to eat correctly than poorly. Proper exercise requires no more than approximately 35 minutes 3 yourself, you recognize it really is based on what you judge as a valuable use of your time. Hum? TV, or a thriving, abundant life.

3. My family won’t be on board with the changes I will need to make.

I recognize this sounds like a silly thought, but also realize it is a real concern for some. You would certainly think that all family members would be on board, however, in infrequent situations a spouse or family member may be negative toward your new enthusiasm. This usually comes down to a lack of understanding of what your lifestyle program entails, as well as some distrust of whether this approach will really work. It may help to steer these family members to our site, www.acueastwest.com and view some of the incredible testimonials from our patients. Without taking the time to learn about our programs and proven success it is only human nature to be cautious. Once familiarizing themselves, you will not only get support, but an accountability partner to help ensure your success.

4. Eating right is too hard and expensive

If you have not been eating right, you should already understand how expensive eating wrong can be. Health deteriorates and medical bills escalate with each year that these poor choices are made. Like any habits, there are good and bad. Once you develop a habit it can be a challenge to change or alter. Once the good or correct habit is developed it will be hard to break. I would challenge anyone to compare grocery bills of a cart full of healthy food compared to one full of junk. And speaking of expense, this is not just a financial term. Losing out on the joys and experience in life because you’re not feeding your body nutritious foods is a terrible, unnecessary expense.

5. I can’t afford a lifestyle program or hire a health coach.

Most people recognize the importance of an education, whether this is a high school, college or even an online education. It’s widely accepted that this is an investment that must be made in order to have the best insurance of meeting our financial needs. The return on this financial investment can materialize into a very secure and abundant life.

Although there are situations in life where funding higher education can seem impossible, we witness people every day finding solutions to get it done. These individuals simply think differently. They do not accept anything less than their God given potential. I am suggesting that your health should be viewed as at least as valuable as your financial situation. What value is wealth if you do not have the health and vitality to enjoy it? At Imagine Wellness, we work with each individual to overcome any financial obstacles. We have solutions to allow those on fixed budgets and retired to easily move forward.

6. I’m afraid that proper lifestyle changes might isolate me from my friends and family.

It is true that not all of your friends will share your newly found optimism toward taking control of your health. Friends who do not place high priority on their health often play down healthy lifestyle choices. Although they may not mean any negative intent, this behavior is sabotaging. In one of my patient member video’s I discuss this as being all too common and some tips to disarm this behavior in a non- confronting manner. The bottom line is those who truly care for you will support your decision to place your health as a priority.

I will always be open and willing to work with any doctor or health professional you currently have. They also, should be open and willing to do the same if the goal is to optimize health and improve lifestyle choices. This includes reducing and/or eliminating unnecessary medications. A doctor’s main concern and intent should always be to aid in the optimization of health in his/her patients. This begins with Do No Harm. I am always cautious of a physician that dismisses any holistic and natural approach to health. In summary, you are ultimately responsible for your health and therefore, the final decision and direction you wish to pursue.

8. I don’t have the self-discipline to make permanent changes.

Self-discipline is not a trait that we are born with, but one that is developed over time through life experience. Discipline coincides with positive experience. In other words, as your actions result in positive changes you will be inclined to continue these actions. One could look at this as positive habits or simply, discipline. Self-< discipline is also strengthened thru accountability held by loved ones, a friend or a mentor.

9. What happens if I commit to a lifestyle program and then hate the experience and give up?

Life is a series of ups and downs. We do not always enjoy the duties required for the end result we are seeking. It’s funny how these duties or actions can initially seem to be difficult or no fun, but later take on an uplifting emotion. This is because we come to recognize the most meaningful successes we have in life came from such actions. Having a successful marriage; raising children; optimizing our health and becoming financial independent all require discipline and actions that sometimes have us wanting to give up and quit. Those of us who continue to play the game are allowed the pleasures of earned rewards.

10. I don’t have the personal confidence to take action.

Very few of us have a natural born instinct of confidence. This comes from continually taking action even when we are fearful. The actual definition for this is courage. As we continue to develop skills from taking these bold steps, we become less fearful or confident. My friend’s son, Landon, has always lacked confidence as he enters a new sport. He is often hesitant to even giving it a try. Once he jumps in, regardless of the fear, he begins to develop skills that ultimately lead to enjoyment and yes, confidence! We are here to mentor you and support you. We do not judge or chastise. We offer an environment that anyone at any level can feel comfortable and genuinely cared for. As you will become very confident.

Informed Consent to Telehealth

To better serve the needs of patients, our services may be available by telehealth (two-way interactive video communication and electronic transmission). This consent explains telehealthcare. If you have any questions, please ask your provider.

I understand that I may be evaluated and treated via telehealth and agree to the following:

1. Telehealth Services: Telehealth involves the transmission of the video or digital photographs of me, and/or details of my health(“Transmitted Data”). All Transmitted Data is sent via electronic means to my provider(s) to facilitate health care services. I understand that:

a)  Telehealth is different from traditional care in that the patient and provider do not meet physically in-person;
b)  Patients will be informed of any additional personnel that is to be present, seen or unseen, during the encounter. Patients must inform their Provider of any person other than the patient who is present. Patients have the right to exclude anyone from either location;
c)  Patients have the right to refuse or stop participation in telehealth services at any time and request an in-person appointment, however, equivalent in-person services might not be available at the same location or time as telehealth services. A refusal to participate in telehealth will not affect rights to future care or benefits to which a patient may otherwise be entitled;
d)  Patients have the right to follow-up with their provider as necessary with questions or concerns;
e)  Benefits of telehealth include that the patients and providers can continue health care services when an in-person appointment is not possible or is inconvenient. The provider can also visualize some of the client’s environment. Telehealth may also minimize exposure to illness;
f)  There are also risks involved in telehealth including, without limit, losing the ability to; a) perform aspects of a physical examination (for example listening to the patient’s heart and lungs or verifying vital signs); b) read physical or vocal cues/tones, and facial expressions; and c) provide immediate emergency physical services/care;
g)  Additionally, technical issues may disrupt the visit. There are also risks to preserving confidentiality including the risk that communications may be overheard, and that communications may be accessed by unknown third-parties; 8) Patients shall have to access to all medical information resulting from the telehealth services as provided by applicable law for patient access to medical records.
2. Confidentiality: All confidentiality protections required by law or regulation will apply to my care. Although confidentiality extends to communications by text, email, telephone, videoconference, and other electronic means, providers cannot guarantee that those communications will be kept confidential and/or that a third-party may not gain access to such communications. With electronic communication, there is always a risk that communications may be compromised, unsecured, and/or accessed by a third-party. To help maintain confidentiality when engaging in electronic health services, it is important that all sessions be conducted in a confidential place. This means that clients agree to participate in telehealth only while in a room or area where other people are not present and cannot overhear the conversation. Do not have sessions in public places. Sessions may not be recorded and patients must seek written permission before recording any portion of the session and/or posting any portion of sessions.

3. Emergencies: Telehealth is not appropriate if I am experiencing an emergent health care situation. If I am experiencing an emergency, I understand that it is my responsibility to immediately call 911. If an emergency develops during telehealth services, I understand that it is my responsibility to immediately inform my telehealth provider, call 911 and stay connected with my telehealth provider (if possible) until help arrives.

I have read and agree to the terms in the Telehealth Consent. I understand that telehealth is not a substitute for personal health care services. I understand that telehealth is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. In case of emergency situations, I will contact 911.