Naples Valley Acupuncture

Naples Valley Acupuncture

Michelle L. Wright, L.Ac.

PO Box 302 , Naples, NY 14512 Phone: (585) 944-7447

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1. PATIENT INFORMATION

Name: ______Date:______

Age: ______Date of Birth: ______Occupation: ______

Address:______City: ______Zip: ______

Best phone # to call: ______cell home work text? yes no

Alternate phone #: ______cell home work text? yes no

Email: ______

Primary Physician: ______Phone #: ______

Emergency Contact: ______Phone #: ______

Relationship: ______

*Medical Insurance Company:______

Policy Holder Name: ______Policy #: ______

*Note: Naples Valley Acupuncture does not currently subscribe to any health insurance networks, however many insurance policies reimburse members for “out-of-network” acupuncture services. We are happy to provide you with a “superbill” that details information insurance companies require for you receive reimbursement for our fees as your policy allows. Please check with your insurance company to see what they cover.

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2. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I received a copy of Naples Valley Acupuncture’s Notice of Privacy Practices, dated 7-31-10.

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Signature of Patient or Personal Representative Date

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Printed Name of Personal Representative Relationship of Personal Representative

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3. PATIENT ADVISORY TO CONSULT A PHYSICIAN

Naples Valley Acupuncture is committed to your health and well-being. While Oriental Medicine has a great deal to offer as a health care system, it cannot totally replace the resources available through biomedical physicians. Consequently, we recommend that you consult your primary care physician regarding any condition(s) for which you are seeking acupuncture treatment.

We, the undersigned, do affirm that ______(patient) has been advised by Michelle Wright, Licensed Acupuncturist, to consult a physician regarding the condition(s) for which the patient seeks an acupuncture treatment.

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Patient SignatureDate

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Michelle Wright, L.Ac. Date

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4. INFORMED CONSENT FOR ACUPUNCTURE TREATMENT

I, ______, consent to acupuncture treatments and other procedures associated with the practice of Traditional Oriental Medicine (TCM) provided by Naples Valley Acupuncture (NVA). I have discussed the nature and purpose of my treatment with Michelle Wright, L.Ac., of NVA. I understand that methods of treatment may include but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, herbal and nutritional recommendations, and bodywork therapies such as medical message and Tui Na (Chinese Massage) and Shiatsu.

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects includingbruising, numbness or tingling near the needling sites that may last a few days, and also dizziness or fainting. Infection is also a risk, although this site uses sterile, disposable needles and maintains a clean and safe environment. Very rare and unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax).

Other TCM therapies also have some side effects and risks. Bruising is a common side effect of cupping. Burns and/or scarring are a potential risk of moxibustion. Recommended herbs and nutritional supplements (from plant, animal and mineral sources) are traditionally considered safe in the practice of Chinese Medicine, however some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

I will notify Naples Valley Acupuncture if I am, or become pregnant.

I do not expect Naples Valley Acupuncture to be able to anticipate and explain all possible risks and complications of treatment.

I understand that Naples Valley Acupuncture may review my medical records and lab reports, and that portions of my records may be used for treatment purposes only. Otherwise, all of my records will be kept confidential and will not be released to any party without my written consent.

By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment, and 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 form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment at Naples Valley Acupuncture.

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(Patient Signature/Signature of Personal Representative)(Date)

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(Print Patient Name) Michelle Wright, L.Ac., MSAOM

FIRST VISIT INTERVIEW FORM