RSVP 1 — Zen Point Acupuncture

Notification Form Regarding Evaluation of Patient by Physician

Important: Read this part about receiving acupuncture in Texas

Texas law pertaining to the practice of acupuncture is a little behind the times.

Prior to providing services - unless treating for chronic pain, smoking, alcohol/substance abuse, or weight loss - Texas acupuncturists are required to determine that a patient has been evaluated for the condition being treated by a physician or dentist within the last 12 months, or referred by a chiropractor within the last 30 days.

As a result, CAC is required to have you respond to the following statements before you may be treated. Please be advised that we will not be permitted to treat you with acupuncture if your response to all of these statements is no.

(Pursuant to the requirements of 22 TAC §183.7 of the Texas State Board of Acupuncture Examiners’ rules (relating to Scope of Practice and Tex. Occ. Code Ann., §205.351, governing the practice of acupuncture.)

Patient's Name

I, (patient's name) am notifying the practitioners at Chinese Acupuncture Clinic of the following:

I have been evaluated by a physician or dentist for the condition being treated within 12 months before the acupuncture was performed. I recognize that a physician should evaluate me for the condition being treated by the acupuncturist.

YES

NO

OR

I have received a referral from my chiropractor within the last 30 days for acupuncture.

YES

NO

After being referred by a chiropractor, if after 120 days or 30 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice whether to follow this advice.

OR

I have not been evaluated by a physician or dentist for the condition being treated, nor have I received a referral from a chiropractor, but I seek treatment for symptoms related to one or more of the following conditions:

Chronic Pain

Smoking Addiction

Weight Loss

Alcoholism

Substance Abuse

Patient Signature

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature:

Patient Information and Consent Form

Please read this information carefully, and ask your practitioner if there is anything that you do not understand.

What is acupuncture?

Acupuncture is a form of therapy in which fine needles are inserted into specific points on the body.

Is acupuncture safe?

Acupuncture is generally very safe. Serious side effects are very rare – less than one per 10,000 treatments.

Does acupuncture have side effects?

You need to be aware that:

drowsiness occurs after treatment in a small number of patients, and, if affected, you are advised not to drive
minor bleeding or bruising occurs after acupuncture in about 3% of treatments
pain during treatment occurs in about 1% of treatments
symptoms can get worse after treatment (less than 3% of patients). You should tell your acupuncturist
about this, but it is usually a good sign
fainting can occur in certain patients, particularly at the first treatment.
In addition, if there are particular risks that apply in your case, your practitioner will discuss these with you.

Is there anything your practitioner needs to know?

Apart from the usual medical details, it is important that you let your practitioner know:

if you have ever experienced a fit, faint or funny turn
if you have a pacemaker or any other electrical implants
if you have a bleeding disorder
if you are taking anti-coagulants or any other medication
if you have damaged heart valves or have any other particular risk of infection.

Single-use, sterile, disposable needles are used in the clinic.

Statement of Consent:

Notice of Privacy Policies and HIPAA Agreement

Protecting your privacy and healthcare information is vital in the course of our relationship. I gather personal information and health information in several ways.

Information I receive from you
Information I receive from other healthcare providers
Information from third party payers.

This information is used for treatment, payment, and healthcare operations. I will use this information for treatment, payment, and healthcare operations. Information will only be disclosed when the law allows me to do so. Any other use and disclosure will be made only with your authorization, and you have the right ot revoke your authorization. You can issue and authorization by writing.

I will not use your information in marketing, without your written authorization. I may send birthday cards, holiday cards, thank you cards, newsletters and appointment reminders, by call, postcards, or letters.

When required by law I may disclose your protected health information. This includes but s not limited to Public Health needs, Health Oversight requirements, and issues of abuse or neglect, legal proceedings.

Patient Rights

Upon written request you have the right to access, review or receive copies of your healthcare records. I will provide copies of your records within 15 days after your request is turned in, and will charge a reasonable, cost-based fee for the records.
You have the right to request that I amend your protected Health Information in writing, within reason of the law, and can receive a copy of Health information. You will receive request within 60 days if in accordance with the law.
You have a right to receive all notices in writing.

HIPAA Acknowledgment:

I acknowledge that I have been provided with Notice of Privacy Policies. I understand that Astra Gordon may need to contact me with appointment reminders or information related to treatments. If this contact is left by phone, a message will be left with a machine or the person who answers. Information stripped of any personal identifiers may be used for research and educational purposes.

First Name

Last Name

Date

MM

DD

YYYY

Patient's Signature

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature:

Zen Point Acupuncture - Intake Questionnaire

Name

First Name

Last Name

Date

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Age

Occupation

Phone

(###)

###

####

Email

Allow email contact by Astra Gordon LAc?

YES

NO

Emergency Contact

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family Physician

Chiropractor

Thank you for coming. Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All your information will be confidential. If you have questions, please ask. Thank you.

Main problem(s):

What diagnosis, if any, have you received for this problem?

When did this problem begin?

Medical History

(Please include the month/year when the event occurred or when the diagnosis was established)

Surgeries:

Hospitalization:

Significant trauma:

(auto accidents, sports injuries, etc)

Allergies:

(drugs, chemicals, foods, environmental):

Medications

(please list all medications you are currently taking, including herbs and supplements)