Initial Patient Form

Initial Patient Information Form

Welcome Information

Welcome to RUYI Acupuncture Integrative Medicine Clinic. We are thoroughly committed to working with you to enhance your health and wellness. We value your time and realize that office visits may be an interruption to an otherwise very busy schedule for you, and we commit to ensuring that your time at our clinic is as focused and efficient as possible.&#13;&#10;Effective medical health care is only possible when the practitioner completely understands the patient’s physical, mental and emotional condition. Oriental medicine is based largely on pattern recognition. Even the smallest details can relate to your overall constitutional picture, so no detail is too small. With that in mind, your thoughtful and honest responses will help to determine an appropriate course of treatment specific to you and allow us to use time in the clinic most effectively. All responses are of course bound to the strict rules of doctor-patient confidentiality.&#13;&#10;&#13;&#10;For your first visit please bring:&#13;&#10;1. An updated list of all medications & supplements you are taking. (space provided on intake form)&#13;&#10;2. Any lab results or relevant imaging received within the last year.&#13;&#10;&#13;&#10;In general, if you are receiving acupuncture, to receive the most benefit, and to avoid side effects, please adhere to the following:&#13;&#10;1. Wear loose clothing.&#13;&#10;2. Have a light meal or snack before the visit, as heavy meals can cause nausea and an empty stomach can be the cause of dizziness or light headache after the treatment.&#13;&#10;3. Do not drink coffee and/or any drink that will stain the tongue several hours prior to your appointment and make sure to drink enough water on the day of treatment.&#13;&#10;4. After your visit, it is preferable that you make the rest of your day as easy as possible. Please avoid heavy exertion. Moderate exercise is okay.&#13;&#10;5. Do not drink alcohol or use other intoxicating drugs, eat greasy or spicy food, or exercise excessively before or after your appointment.&#13;&#10;&#13;&#10;We are looking forward to working with you, Stay Rejuvenate, Revitalize and Relax!

First Name:

Last Name:

Date of Birth

Date

Age

Today

Date

Gender:

Contact Phone Number:

Area CodePhone Number

Home Phone Number:

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email:

Occupation:

Emergency Contact Person:

First NameLast Name

Emergency Contact Phone Number:

Area CodePhone Number

Relationship with Emergency Contact:

How did you hear about us?

Chief Complain. Please describe your current health concerns?

Severity of the condition / Pain Scale

Are you aware of any allergies to food, drugs, or other environmental allergens?

Do you take any of the following medications more than once a week?

Please list all Prescribed Medications you are regularly taking, including dosage and frequency, if possible:

Please Indicate if you have any of the following:

Did you visit a doctor's office, clinic or hospital, ER recently? For what reason?

What hospitalizations, injury or surgeries have you had in the past?

What diagnostic imaging studies have you had?

Do You currently have a primary care doctor?

Primary Doctor's Name:

Primary Doctor's Phone Number:

Area CodePhone Number

Are you currently under the care of any other physician/healthcare providers ?

1st Doctor's Name:

1st Doctor's Phone Number:

Area CodePhone Number

2nd Doctor's Name:

2nd Doctor's Phone Number:

Area CodePhone Number

Family Medical History (Do you have a family history of any of the following ?)

General

Psychology

Endocrine

Skin

Neurologic

Scalp/Head

Eyes

Ears

Nose

Mouth

Allergy

Lungs

Heart

GI/Abdomen

Genitourinary/Urology

Blood/Lymph

Women Only

Men Only

Age of FIRST Menstruation

Age of LAST Menstruation

Period every (days)

Number of days of flow

Number of Pregnancy

Number of Live Births

Are you Pregnant or Breastfeeding?

Other Concerns

Print Name

Signature (or Patient's Representative)

Date

MonthDayYear

THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, paying your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital administration.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to quality assessment activities, employee review activities, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
Use Required by Law: We may use or disclose your protected health information in the following situations without your authorization. These situations include as Required by Law; Public Health issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors; Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; or for Inmates. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500
Other Permitted and Required Uses and Disclosures will Be made only with your consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Agreed by signing below

Print Name

Signature (or Patient's Representative)

Date

MonthDayYear

Article 1:  Agreement to Arbitrate:  It is understood that any dispute as to medical malpractice, that is as to 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.  Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis.  An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims. &#13;&#10;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 binds 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 backup 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.  &#13;&#10;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 law, 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. &#13;&#10;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. &#13;&#10;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. &#13;&#10;Article 6:  Retroactive Effect:  If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initial below.   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.  NOTICE:  BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.  SEE ARTICLE 1 OF THIS CONTRACT.

Agreed by signing below

Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initial here.initialEffective as of the date of first professional services.

Print Name

Signature (or Patient's Representative)

I hereby request and consent to acupuncture and associated treatments and procedures having to do with holistic medical care within the scope of practice of acupuncture for myself, (or for the patient named below for whom I am legally responsible) by Dr. Louie Lu, DAIM. L.Ac.
  I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, gua-sha, electro-acupuncture, tui-na (Chinese manual therapy), herbal medicine, exercise and/or nutritional and lifestyle counseling and coaching. I understand that herbs may need to be prepared and that teas be consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify my practitioner or a member of the clinical staff of any unanticipated or unpleasant effects associated with the treatment and/or consumption of herbs.
  I understand that acupuncture is a generally safe method of treatment that involves the insertion of subcutaneous needles at various points in the body. I acknowledge that acupuncture may occasionally have some side effects including bruising, numbness, tingling, or pain near the needle site that may last a few days, as well as dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps or hot packs. 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 Oriental manual therapy (including all bodywork procedures, cupping, gua-sha, and qigong therapy/energy work) could constitute a wide range of manually applied techniques that could include, but are not limited to, light touch, deep pressure, and joint mobilization through stretching and passive range of motion. I understand that any or all aspects of Oriental manual therapy may result in fatigue, nausea, malaise, soreness, bruising, and aching for multiple days after treatment and that bruising is a common side effect of cupping and gua-sha. Emotional release and regression to past traumatic events may also result from any or all aspects of treatment.
  The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that I have been recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs and other treatment methods 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 my practitioner if I am now or become pregnant or if any of these side effects occur.
  I understand that while this document describes the major risks of treatment, other side effects and risks may occur. As with any medical or health-related treatment, I understand that it is impossible to accurately predict how any one person may respond to treatment and I acknowledge that, in extreme and very rare circumstances, adverse side effects may even result in blindness, disability, and/or death.
    I understand that acupuncture and Oriental medicine treatment is not a replacement for diagnostic medical procedures. I understand that an acupuncturist does not diagnose according to standard medical practice, nor should an “Oriental Diagnosis” be considered a replacement for standard medical evaluation or testing. I acknowledge that my practitioner is not a Primary Care Doctor, Medical Doctor, Naturopathic Doctor, Doctor of Osteopath, Doctor of Chiropractic, nor Doctor of Physical Therapy and does not claim to practice within the scope thereof.
  By 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 and release form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
  I hereby agree to indemnify and hold harmless Dr. Louie Lu, DAIM. L.Ac from any loss, liability, damage, judgment awards, or costs, including court costs and attorneys’ fees that may incur due to my participation in said treatment or subrogation suits or claims, whether caused by the negligence of Releases or otherwise.
  I have carefully read this form and fully understand its contents. All information I have provided in any and all intake forms is true. I am aware this is a release of liability, a waiver of claims, an agreement not to sue, an indemnity, and a contract between myself and the Releases described herein. I sign it of my own free will.
  PARENT OR GUARDIAN OR LIAISON OF SUCH, OF A MINOR: I, as parent or guardian or liaison of the below-named minor, hereby give my permission for this child or ward to participate as a patient in the above-named treatment(s), and further agree, individually and on behalf of this child or ward, to the terms as outlined herein.

Agreed by signing below

Print Name

Signature (or Patient's Representative)

Date

MonthDayYear

We respect the fact that you may, on occasion, need to cancel an appointment. However, we do request 24 hours' notice. Should you cancel or reschedule an appointment without 24 hours' notice, we reserve the right to charge a Late Cancellation Fee of Forty-Eight ($48) dollars. Missed Appointment (No Show) Fee of Eighty-Eight ($88) dollars.&#13;&#10;&#13;&#10;You may or may not be charged this fee depending upon the circumstances and/or number of occurrences. The patient also acknowledges that repeated Late/Same Day Cancellations or No-Shows for scheduled appointments may result in my discharge from the practice or I may be required to pay upfront for the cost of my services at the time of pre-scheduling.

Agreed by signing below

Signature (or Patient's Representative)

Date:

MonthDayYear

A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. Insurance Liability for Payment: Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Every effort will be made by this office to have all services and procedures preauthorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. &#13;&#10;&#13;&#10;I understand that my health insurance company may deny payment for the services identified above, for the reasons stated. If my health insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies.

By signing below, I confirm the amount of payment made by me, and I understand that the payment (or no payment) is an estimate of my financial responsibility for the service rendered today. My final responsibility is based on the Explanation of Benefits. Any under-collection will be billed to me. Over-collection is refunded to me quarterly. Agreed by signing below

I, the undersigned patient, hereby consent to the use of Artificial Intelligence (AI) scribe technology in the documentation of my medical records at RUYI Acupuncture.&#13;&#10;AI scribe technology is utilized to assist in documenting medical information by converting spoken words into text in an efficient and accurate manner. This technology may be used to generate clinical notes, reports, and other relevant documentation for my care.&#13;&#10;During my medical appointments, portions of the conversation between myself and my healthcare provider may be audio recorded and processed using AI scribe technology. The AI system transcribes spoken words into text to assist in the creation of clinical documentation. The AI scribe is used solely for documentation purposes and does not make any clinical decisions. My provider will review and finalize all documentation before it becomes part of my medical record.&#13;&#10;Audio recordings are not part of the permanent legal medical record. Only clinically relevant information is included in the official medical record. Audio data is stored securely and retained only for a limited period of time to support documentation and quality assurance, after which it is deleted in accordance with system policies.&#13;&#10;The medical practice employs robust security measures to safeguard the confidentiality and integrity of information processed through AI scribe technology. These measures include encryption, access controls, and regular security reviews to prevent unauthorized access and protect against data breaches.

Do you consent to the AI Scribe?

I understand that I may decline or withdraw consent for the use of AI scribe technology at any time. If I choose to opt out, my provider will document my visit using standard manual methods, and my care will not be impacted.&#13;&#10;I have read and understand the information provided in this consent form. By signing below, I voluntarily consent to the use of AI scribe technology, including audio recording and transcription, for the creation of my medical records at RUYI Acupuncture.

Patient Signature (if Parent / Guardian, please sign patient's name on behalf of patient)

Medical Insurance Name

Member ID Number

Group No#

Copy of Driver's License Front Only

Upload Driver's License or ID front side only

Copy of Insurance Card Front & Back

(Upload Medical Insurance Card Front/Back)

Patient Information

Initial Patient Information Form

Review of Systems

Female Reproductive

I feel that I have answered the above questions to the best of my ability and understand that if I choose to omit any health information I do so at my own risk and that in no way will the healthcare provider be responsible for any omitted information.

HIPAA Notice of Privacy Practices

ARBITRATION AGREEMENT

ACUPUNCTURE INFORMED CONSENT TO TREAT

Late Cancellation/ Missed Appointments Notices

Insurance Disclaimer

Consent to AI Scribe

Medical Insurance Information