PATIENT REGISTRATION FORM

Transcription

1 PATIENT REGISTRATION FORM Full Name: Date of Birth: Marital Status: Gender (circle one): Female Male Home Address: City: State: Zip: Address: May we send you promotions to the above address? Yes No Mobile Phone: ( ) Home Phone: ( ) Occupation: Employer: Primary Care Physician: Phone: ( ) Date of Last Visit: Emergency Contact: Phone: ( ) Relationship: How did you hear about us? (circle one) Google Search Facebook Printed Ad or Brochure Referred by Doctor (Doctors Name): Referred by Friend or Patient (Name): If by another patient, may we thank them by letting them know you came in? Yes No By my signature, all information above is true to the best of my knowledge. Signature: Date:

2 AUTHORIZATION FOR TREATMENT 1 of 2 I, ( ) undersigned, (a parent of a minor), (guardian of), (guardian advocate of), a patient of, LLC., and the subject of this authorization, hereby authorize treatment by the Acupuncture Physician and qualified staff of, LLC. I understand that methods of treatment may include, but are not limited to, acupuncture, acupressure, electrical stimulation, moxibustion, cupping, massage, tui-na, reflexology, Chinese and/or Western herbal medicine, dietary and nutritional counseling, homeopathic remedies, biomagnetic therapy, injection therapy, biopuncture, injection therapy, vitamin injections, european facials, facial chemical peels,dermapen microneedling, microdermabrasion, skin treatments, allergery (NAET) treatments, laser, skin care counseling and skin care recommendations, ear tacks, ear seeds and prevented and corrective exercises and stretches. Additionally, I understand that treatment performed by the acupuncture physician and qualified staff of, LLC, should not be considered a substitute for treatment from a qualified Western medical doctor. I understand that treatment and advice offered should not be construed to be a Wester medical diagnosis or treatment of any disease or injury, and that I should always consult my allopathic physician for any medical conditions. Acupuncture consists of the insertion of very fine needles through the skin at specific points on the surface of the body (small amounts of electrical current may be applied to the needles). Acupressure involves the stimulation of acupuncture point with pressure, using either the fingers or special instruments such as an activator, instead of needles. Moxibustion consists of the application of heat to points or certain locations on the body using moxa (a preparation of the herb Artemisia Vulgaris) in the form of a cone, stick, spray, cream or balm. Moxibustion is often combined with acupuncture in clinical practice. Cupping is a therapeutic approach wherein small glass or plastic jars, in which a vacuum is created, are attached to the skin surfaces at various locations. In accordance with Center for Disease Control and Prevention guidelines, each acupuncture point is wiped with alcohol prior to needle insertion. All needles and lancets used at Roxy Barber Acupuncture & Aesthetics, LLC are pre-sterilized, disposable and one time use. I have been informed that acupuncture is a safe method of treatment, but occasionally complications may result from any of the above and below treatments. Among these possible complications are: bruising and/or hematoma (a swelling under the skin caused by a break in a blood vessel) at the needling sites that may last a few days, numbness, tingling, local redness, irritation, pain, discomfort, and temporary aggravation of present symptoms. There have been very rare instances reported of infections at the needling site, and psychosomatic reactions to needling such as nausea, weakness and fainting. There have been extremely rare instances of spontaneous miscarriage and pneumothorax (a collection of in in the pleural cavity). Injection therapy/biopuncture consists of vitamin and/or homeopathic remedies injected into acupuncture points. All hypodermic needles and syringes used at, LLC are pre-sterilized and disposable.

3 AUTHORIZATION FOR TREATMENT 2 of 2 The herbs, homeopathic remedies 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. I understand that some herbs may be inappropriate during pregnancy and will notify the acupuncture physician and qualified staff at, LLC if I am, become or am planing on becoming pregnant. If I experience any gastro-intestinal upset or allergic reactions to the herbs, I will inform the acupuncture physician immediately. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and to discuss with the acupuncture physician, qualified staff and/or office staff the nature, consequences, side effects, and benefits of acupuncture treatments and other procedures, releasing that no guarantees have been given to me by Roxy Barber Acupuncture & Aesthetics, LLC, or any of its personnel regarding cure or improvement of my conditions a result of the above-mentioned procedures. By signing below I agree to the above named procedures, and intend this consent for to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I understand that i am free to withdraw my consent and to discontinue participation in this treatment at any time. Patient s Printed Name: Patient s Signature: Date: For Personal Representative of the Patient (if applicable) Print Name of Personal Representative: Describe Personal Representative Relationship: (Parent, Guardian, etc.) Signature of Personal Representative: Date: Witness:

4 HEALTH HISTORY QUESTIONNAIRE 1 of 5 Name: Date: Age: Are you currently receiving healthcare? Yes No If yes, where and from whom? If no, where did you last receive health care? For what reason? What health concerns have brought you here today? Please list in order of importance. Condition Past Treatment Females: Do you have any reason to believe you are pregnant? Yes No Do you have any chronic infectious disease (ex: HIV, Hepatitis, etc.)? Yes No If yes, please explain Do you suffer from any chronic illnesses? Yes No If yes, please explain Please list any allergies or hypersensitivities (medications, foods, environmental) List all prescribed medications: Over-the-counter medications: Vitamins, supplements herbs: Height: Weight: Last blood pressure reading & Date, if unknown, is blood pressure normally normal?

5 HEALTH HISTORY QUESTIONNAIRE 2 of 5 Hospitalizations & Surgeries (Reason & Date): X-Rays / CT Scans / MRI s / Special Studies (Reason & Date): Family History, please identify if your parents, grandparents, brothers, sisters &/or children have had any of the following along with the TYPE & DATE: Cancer: Diabetes: Mental Illness: Heart Disease: Stroke: Personal Health History, please CIRCLE below those that you experience recently and in the past. Write when, if in the past. Head, Ears, Nose & Throat: Headaches Impaired Vision Eye Pain/Strain Glaucoma Tearing Dry Eyes Hay Fever Impaired Hearing Ear Ringing Earaches Sinus Problems Nose Bleeds Frequent Sore Throat Teeth Grinding/Clenching TMJ/Jaw Problems Respiratory: Pneumonia Pleuritis Asthma Emphysema Tuberculosis Persistent Cough Difficulty Breathing Shortness of Breath Frequent Common Colds Cardiovascular: Heart Disease Heart Murmur Chest Pain Rheumatic Fever Stroke High Blood Pressure Low Blood Pressure Palpations/Fluttering Pacemaker Swelling of Ankles Varicose Veins Pace Maker Other:

6 HEALTH HISTORY QUESTIONNAIRE 3 of 5 Gastrointestinal: Ulcers Changes in Appetite Nausea Vomiting Epigastric Pain Bowel Problems Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hepatitis B or C Abdominal Pain Hemorrhoids Hernia Constipation Diarrhea Stools: Blood in Stool Undigested Food Diarrhea Constipation Mucous How often do you have a bowel movement? Urinary: Kidney Disease Painful Urination Frequent Urinary Tract Infections Impaired Urination Frequent Urination Kidney Stones Blood in Urine Cloudy Urine Male Reproductive: Sexual Difficulties Prostate Problems Testicular Pain/Swelling Penile Discharge Venereal Disease Other: Female Reproductive: Irregular Cycles Breast Lumps Breast Tenderness/Swelling Vaginal Discharge Bleeding Between Cycles Heavy Flow Clotting Venereal Disease Premenstrual Problems Menopausal Symptoms Difficulty Conceiving Sexual Difficulties Neurological: Dizziness/Vertigo Paralysis Numbness Tingling Loss of Balance Seizures Epilepsy Other: Musculoskeletal: Muscle Spasms/Cramps Neck Pain Shoulder Pain Upper Back Pain Mid Back Pain Low Back Pain Sciatic Pain Arm Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Leg Pain Knee Pain Ankle Pain Foot Pain Endocrine: Hypothyroid Hyperthyroid Hypoglycemia Diabetes Night Sweats Feeling Hot or Cold Other:

7 HEALTH HISTORY QUESTIONNAIRE 4 of 5 Energy & Immunity: Fatigue Slow Wound Healing Chronic Infection Emotional: Mood Swings Nervousness Anxiety Depression Skin: Rashes Hives Eczema Dry Skin Shingles Acne Other: Miscellaneous: Anemia Cancer Cold Hands/Feet Pregnant Is there anything else I should know? Diet: Do you eat fast food? Yes No Do you eat red meat? Yes No Do you eat/drink Dairy? Yes No Are you Vegetarian or Vegan? (Please circle one) Daily water intake: Nicotine / Alcohol / Caffeine / Recreational Drug Use: Exercise: Sleep: Hours per night on average: Number of times you wake during the night: Dreaming? Yes No Nightmares / Night-terrors? Yes No Occupation:

8 HEALTH HISTORY QUESTIONNAIRE 5 of 5 Major traumas? Yes No If yes, please explain: Hobbies & Interests: The information I have given on the health history form is correct to the best of my knowledge. Patient s Printed Name: Patient s Signature: Date: For Personal Representative of the Patient (if applicable) Print Name of Personal Representative: Describe Personal Representative Relationship: (Parent, Guardian, etc.) Signature of Personal Representative: Date: Witness:

9 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, the undersigned, (a patient of a minor), (guardian of), (guardian advocates of), a patient of, LLC, herby acknowledge that I have been given a copy of the complete version of the Notice of Privacy Practices of Roxy Barber Acupuncture & Aesthetics, LLC, and that I have reviewed the Notice of Privacy Practices in full, and have been given the opportunity to discuss with my practitioner or qualified staff of Roxy Barber Acupuncture & Aesthetics, LLC, any questions I have regarding its content. Patient s Printed Name: Patient s Signature: Date: For Personal Representative of the Patient (if applicable) Print Name of Personal Representative: Describe Personal Representative Relationship: (Parent, Guardian, etc.) Signature of Personal Representative: Date: Witness:

10 FINANCIAL HARDSHIP PAYMENT AGREEMENT Date: Patient Name: Doctors Name: Dr. Roxy Barber I hereby certify that I have been informed of the usual fees for the examination, testing and treatment that have been recommended. I am unable to pay those fees at this time without substantial financial hardship and peril. I have no expectation of being able to recover those expenses from any third party or insurance benefit. To enable me to obtain the recommended services Dr. Roxy Barber, DOM, AP, LE and I have agreed to a special payment arrangement for what I will pay each visit. It is my responsibility to make these payments without any need for periodic bills or other reminders of payments due. Patient Signature Witness Signature Print Patient Name Print Witness Name

11 Dermapan Consent & Release Form Patient s Name (PRINT) To the patient: It is important that you are informed about your skin condition and proposed treatment including the potential benefits and risks involved. This disclosure is not meant to scare or alarm you; it is simply an effort to better inform you so that you may give or withhold your consent to the treatment program. I of (address as above) have requested a Dermapen Treatment to attempt to improve my facial expression lines and or skin surface with Dermapen treatment. The practice of medicine is not an exact science and no guarantees can be or have been made concerning expected results. I understand that several appointments may be necessary to complete the treatment. Risks and side effects: Side effects and complications are usually minimal. Occasionally you may experience erythema, bleeding, temporary scarring, dryness and or discomfort. I have been advised of the risks involved in such treatment, the expected benefits of such treatment, and alternative treatments, including no treatment at all. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and that I have had sufficient opportunity for discussion and to ask questions. I consent to this procedure today and for all subsequent treatments. Patient s Signature: Practitioner s Signature: Date: Date: Photography / Video Release TREATMENT MODEL CONSENT FORM As part of your treatment we will be photographing the treatment area of your body/face (and in some cases, filming the treatment process). This will allow us to visually monitor your individual progress and see the results of your treatment over time. We would appreciate your willingness to share your outcomes and results with others, for both training and marketing purposes within the beauty, cosmetic and aesthetic industry. In all cases we will do everything we can to keep your identity anonymous. With this form I, (participants name) give my full consent for all photographs/footage captured before, during and after my treatment by, (clinic/practice name) to remain the property of the clinic and the aesthetic equipment supplier Dermapen. With this consent, I give permission for the images/footage (if they are to be selected) to be used in the following and similar materials: (Please pick one or both preferences) Marketing and advertising for either the clinic or Dermapen to be used on company websites, in-clinic waiting room materials or other such industry media channels. Examples are product/treatment brochures, clinic advertising material and information made available to other clients interested in the treatment. In training purposes, educational material for the clinics, Dermapen and internal use only. Such as user product manuals, educational charts and industry communications. Signature Date: