Alternative Community Intake

***Please wear or bring loose-fitting, comfortable clothes that allow access up to elbows and knees, and/or to your area of concern (shoulders, neck, back, etc.) if possible***

All information entered on this form is confidential. Only licensed practitioners and Winding Path Acupuncture staff will have access to this information.

Client Medical History

Clinic Policies:

Our office policy requires payment on the day of your visit.

Kindly allow 24-hour minimum notice for change or cancellation of appointment. No shows will owe for full value. We absolutely forgive emergencies.

There will be a $30.00 fee for returned checks.

Client services and chart information are confidential. Written authorization is required from you to release any information. Please turn off your mobile phone for optimal relaxation 

Client Agreement: I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status. I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Winding Path Acupuncture and my practitioner from any liability whatsoever arising from failure on my part.

I, the undersigned, have read and understand the above policies:

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. 

HIPAA NOTICE OF PRIVACY PRACTICES

We understand that health information about you and your health is personal. Winding Path Acupuncture  is committed to protecting your personal health information. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office. This tells you the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

• Make sure that health information that identifies you is kept private

• Give you this Notice of our legal duties and privacy practices with respect to health information about you

• Follow the terms of the Notice that is currently in effect

How we may use and disclose health information about you:

• For treatment

• For payment

• For health care operations

• For appointment reminders

• As required by Law

• To avert a serious threat to health and safety

• Health oversight activities

• Lawsuits and disputes

Your rights regarding Health Information about you:

• Right to Inspect and copy

• Right to Amend

• Right to an Accounting of Disclosures

• Right to Request Restrictions

• Right to Request Confidential Communications

• Right to a Paper copy of this Notice. Notice is available upon request.

Effective date, November 1st, 2019

Recommendation for Examination by a Physician