New Patient Form
Date: December 5, 2020
For your safety and protection and for our information, please answer the following questions relevant to you:
39. Based on your food intake for one day, what do you typically eat?
43. How many cups do you drink per day of the following beverages?
Bodily Functions - Signs/Symptoms:
PLEASE NOTE: In Traditional Chinese Medicine, all illness stems from an imbalance in one of the five main organs, heart, liver, lungs, kidney and spleen. These questions are grouped into symptoms of illness for each organ to determine which is out of balance. Complete these questions as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. By filling this in we will be able to give you an idea of how your conditions relate to the organs according to Chinese Medicine. All information is strictly confidential.
55. Do you experience musculoskeletal pain? (e.g. joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) If yes:
Men's Health- please skip if this section does not apply to you
Women's Health - please skip if this section does not apply to you
Health & Wellness Levels:
77. Many factors affect our lives in various ways. These factors weave a web of health and wellbeing.
Please rate your level of satisfaction in each of the areas (1 = Not happy at all, 10 = Very happy):
In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of access to and correction of your personal information held by this practice. No information will be given to a third party without your permission.
Consent to Treatment
I HEREBY give my consent for acupuncture/acupressure treatment bearing in mind that a full verbal explanation has been given at the time of treatment.
I AGREE to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.
I UNDERSTAND that I must pay for private treatments, cancellation fees and the costs of materials (splints, strappings etc.) and herbs, and any treatments declined by ACC/work insurance.
I UNDERSTAND that herbs are not refundable.
I UNDERSTAND that any unpaid bills may be referred to a debt collector and I agree that I will be responsible for the debt collection fees, and the administration fee of $50 incurred for accounts sent to debt collection.
I UNDERSTAND that I have the right to decline part or all of the treatment offered to me at any time and I can ask for a second opinion or change my treatment provider in accordance with Section 7 of the Code of Health & Disability Services Consumer Rights 1996.
I UNDERSTAND that I can ask the staff for an explanation of treatment I am receiving at any time and that in accordance with Section 10 of the Code of Health and Disability Services Consumer Rights 1996, I have the right of complaint.
I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a fee of the full price of treatment should I not give sufficient notice.
It is our policy to collect private payment for ACC treatments until the ACC claim is showing on the ACC website as being approved. We will refund the difference once the claim is approved.