TEMPE COMMUNITY ACUPUNCTURE (480)269 0415 WWW.TEMPEACU.COM HEIDI@TEMPEACU.COM Welcome to Tempe Community Acupuncture! TCA is one of many community acupuncture clinics established in the country who are members of POCA, a multi-stakeholder cooperative whose mission is to make acupuncture affordable for nearly everyone; while promoting a sustainable business model that works for patients and practitioners. To jump on board, learn more about the cooperative and to find POCA member clinics near you, visit www.pocacoop.com We Have a Sliding Scale We offer treatments on a sliding scale of $15-$35 with an additional one-time $10 new patient fee for the first appointment. You decide what you can afford. There is never any need to prove your income. Acupuncture is most effective for current health concerns when it is done frequently and regularly. We've found this to be especially true at the beginning of a course of treatment. Acupuncture is a PROCESS. It is very rare for any person to be able to resolve a problem completely with one treatment. Frequent treatment is much more likely to lead to relief. Your acupuncturist will suggest a course of treatment based on the intensity and duration of your health concern. If you don t come in often enough or for enough treatments, acupuncture may not work as well for you. We Treat in a Community Room We believe a group setting has many benefits: it s easier for friends and family to come in together and it allows patients to keep their needles in as long as they want. Most people learn after a few treatments when they feel 'done' or 'cooked'. This can take anywhere from twenty minutes to an hour or two. The treatment room is meant to remain a quiet space for you and others to rest, sleep and let the acupuncture do its thing. Its atmosphere exists through our patients relaxing together. Maintaining this reservoir of calm requires very little talking in the clinic space including us. It is also important to turn cell phones completely off before entering the community room. Lights from phones can be just as distracting as noises. Thank you and we look forward to working with you!!!
HEALTH HISTORY TEMPE COMMUNITY ACUPUNCTURE (480)269 0415 WWW.TEMPEACU.COM HEIDI@TEMPEACU.COM. PATIENT INFORMATION Name Address CONTACT INFORMATION Telephone Email City, State, Zip Age Birthdate Emergency Contact Occupation Primary physician Primary physician telephone Name Relationship Telephone How did you hear about us? HEALTH HISTORY What are your primary concerns for coming in for treatment? 1. 2. 3. How is your sleep? How is your digestion? List all medications or vitamins that you are currently taking. List all serious illnesses, accidents, or surgeries.
HEALTH HISTORY Check symptoms you have had in the last year: o Depression o Difficulty concentrating o Dizziness o Excessive worry o Excessive fear o Excessive anger o Fatigue o Headaches o Nervousness/irritability Check conditions you have had in the past: o AIDS o Allergies o Anemia o Arthritis o Bleeding disorders o Breast lump o Cancer o Diabetes o PCOS Please check all that apply: o Tremors o Swollen joints o Pain o Asthma o Blurred/failing vision o Difficulty breathing o Earache o Eye pain o Frequent colds o Allergies/ hay fever o Nose bleeds o Hearing loss o Cough o Ringing in ears o Bruise easily o Dry skin o Itching/rash o Sore that won t heal PAGE 2 Please check all that apply: o Blood/pus in urine o Frequent urination o Kidney infection/stones o Low libido o Chest pain o High or low blood pressure o Pain over heart o Poor circulation o Previous heart attack o Rapid/irregular heart beat o Gas or bloating o Constipation o Diarrhea o Distention of abdomen o Excessive hunger o Gallbladder trouble o Hemorrhoids o Indigestion o Nausea o Stomach pain o Poor appetite o Vomiting o Erection difficulty o Prostate trouble o Bleeding between periods o Clots in menses o Excessive menstrual flow o PMS o Irregular cycle o Menopause o Miscarriage o Light menstrual flow Could you be pregnant? SIGNATURE By signing below I agree that the information on this form is correct to the best of my knowledge. SIGNATURE DATE.
TEMPE COMMUNITY ACUPUNCTURE (480)269 0415 WWW.TEMPEACU.COM HEIDI@TEMPEACU.COM Payment is due at the time of service and may be paid by cash, check, Visa, Mastercard or American Express. There will be a $35 fee for any returned checks. In order to keep our rates affordable, we do not file insurance claims of any kind and are not a Medicare/Medicaid provider. We can provide you with a receipt that you may present to your insurance provider. Cancellation Policy Tempe Community Acupuncture works to make our services available to as many people as possible, and at the most affordable rates. With respect to this goal we ask for 12 hours advance notice if you need to cancel or reschedule an appointment. You may cancel or reschedule an appointment by phone or by using our online scheduling system. You may also send us an email or leave us a voicemail outside of normal business hours. Please note that there is a $10 cancellation fee for missed appointments or appointments that are cancelled/rescheduled with less than 12 hours notice. Thank you for your understanding. I affirm that I have read the payment and cancellation policies and that I am aware of the $10 cancellation fee for late cancellations and missed appointments. Patient s Name Date Signature Payment Policy
INFORMED CONSENT Informed Consent to Acupuncture Treatment I, the undersigned, hereby request and consent to treatment by acupuncture and/or other procedures within the scope of the practice of Oriental Medicine. I am hereby informed that the treatment methods are all generally safe, but there may be some side effects or risks. Acupuncture involves the insertion of special needles into particular points on the body. There are some risks to treatment, including bruising of the skin and/or slight bleeding, weakness, fainting and aggravation of symptoms existing prior to acupuncture treatment. As with any invasive procedure there is a risk of puncturing organs (this is extremely rare). At the site of the needle insertion there may be soreness, numbness, tingling, or swelling. There is a small risk of infection at the needle site. TCA uses only one-time use, sterile disposable needles. We do not reuse needles, even at different areas of the body for the same person. The herbal supplements recommended at TCA are generally mild and very safe. There are possible side effects including: nausea, gas, stomachache, diarrhea, and headache. I understand I must stop takin my herbs and notify the clinic immediately if I experience any discomfort or adverse reactions. We do not provide primary care, nor Western (allopathic) medical care. Please see your medical doctor for those services and for routine check-ups. If you are pregnant, have a bleeding disorder, pacemaker, high blood pressure, local infection or have been prescribed anticoagulant medications like Coumadin, by signing below you state that you have informed your acupuncturist of such conditions. The procedures have been explained to me and I understand that I have the right to refuse any part of treatment. I understand that I can discuss risks and benefits further with my practitioner before signing if I so choose, although I do not anticipate and expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her judgment in my best interest during course of treatment, based upon the facts then known. Although I am aware that acupuncture and other procedures within Oriental Medicine have helped millions of people, I understand that no guarantee of cure of improvement in my condition is given or implied. I have read, or have had read to me, this informed consent form. I have also had the opportunity to ask questions about its content, and by signing below, I agree to a course of treatment in Oriental Medicine. I intend this consent form to cover my entire course of treatment for my present condition and for any future condition(s) for which I seek treatment with this practitioner. I understand that the treatment here is not a replacement for medical care. With this knowledge, I voluntarily consent to the above procedures. Patient s Name Date Signature