Significant Health History Information
Have you ever had, or do you presently have, any of the following significant health issues?
Form to be completed by patient notifying the acupuncturist as towhether he/she has been evaluated by a physician, and other information(Pursuant to the requirements of Rule 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.)
I patient's name am notifying the staff and acupuncturist(s) of Eastern Balance Oriental Medicine, LLC clinic of the following:
I have been evaluated by a physician or dentist for the condition being treated within the twelve (12) monthsbefore the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for thecondition being treated by the acupuncturist.
Initials of patient(initials) Date: blank
I have received a referral from my chiropractor within the last 30 days for acupuncture. After being referred bya chiropractor, I understand that the acupuncturist is required to refer me to a physician if no substantialimprovement occurs in the condition being treated after 120 days or 30 treatments, whichever comes first. It ismy responsibility and choice whether to follow this advice.
… an acupuncturist holding a current and valid license may without an evaluation or a referral from a physician, dentist, or chiropractor perform acupuncture on a person for smoking addiction, weight loss, alcoholism, chronic pain, or substance abuse.
INFORMED CONSENT TO TREATMENT
I hereby request and consent to the performance of Traditional Chinese Medicine (TCM) treatment and other procedures within the scope of practice of TCM on me (or on the patient named below, for whom I am legally responsible) by any licensed acupuncturist who now or in the future treat me while working or associated with Eastern Balance Oriental Medicine, LLC.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxabustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling.
I have been informed that acupuncture is a safe method of treatment, but that it may have some side effects, including: bleeding, bruising, numbness, soreness, or tingling near the needling sites that may last a few days, and dizziness and fainting.
The clinic uses sterile single-use disposable needles and maintains a clean andsafe environment.
Burns, blistering, and/or scarring are a potential risk of moxabustion or cupping, or when treatment involves the use of heat lamps. Bruising is also a common side effect of cupping.
I understand that herbs may need to be prepared and teas consumed according to the instructions provided orally and in writing. I further understand that these prescribed herbs may have an unpleasant smell or taste,and I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. The herbs and nutritional supplements (which are from plant, animal, andmineral sources) that have been recommended are considered safe in the practice of acupuncture, although some may be toxic in large doses.
Some possible uncomfortable effects of taking herbs are nausea, gas,stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that some herbs may be inappropriate during pregnancy. I will notify a clinical staff member who is caring for me if I am or become pregnant.
I fully acknowledge and specifically state that I understand that treatment with TCM (like treatment by other branches of health services) cannot, will not, and does not guarantee specific result or cure, and treatment with TCM, just like leaving my condition untreated, carries risk. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.
I understand that 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.
I understand all fees are due and payable at time treatment is given. Eastern Balance Oriental Medicine, LLC. will provide me with the appropriate receipt for filling with my insurance carrier. TCM treatment coverage by insurance varies by policy and company, and I should read my policy or check with my insurance company to determine eligibility for benefits in my case.
I acknowledge that Eastern Balance Oriental Medicine, LLC. is notresponsible for any denial of claim from my insurance company. TCM is a lawfully deductible medical expense for purposes of U.S. Federal Income Tax. TCM treatment is currently not covered by Medicare.
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 TCM treatment modalities, and have had an opportunity to ask questions.
I acknowledge that I am legally and mentally competent to sign this authorization and that I do fully understand it, I intend this consent form to cover the entire course of treatment for my present condition and forany future condition(s) for which I seek treatment.