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  • Initial Patient Information Form

     
  • YOUR PRIVACY IS OUR PRIORATY, this form is under HIPPA Compliance.

  • Patient Information

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  • Review of Systems

    (Check any symptoms that you have)
  • 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.

    Agreed by signing below
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  • HIPAA Notice of Privacy Practices

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  • ARBITRATION AGREEMENT

  • 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..  Effective as of the date of first professional services.

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  • ACUPUNCTURE INFORMED CONSENT TO TREAT

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  • Late Cancellation/ Missed Appointments Notices

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  • Insurance Disclaimer

  • 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

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  • Medical Insurance Information

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