Loading...

New Patient Waivers

Informed Consent to Traditional Chinese Medicine (TCM) Health Care

I hereby request and consent to the performance of the following on myself (or the patient named below, for whom I am legally responsible) by the practitioners on staff at As You Are Acupuncture who now or in the future treat me while employed by, working or associated with or substituting for As You Are Acupuncture, including those working at this clinic, or any other associated clinics:  acupuncture and other Traditional Chinese Medicine (TCM) procedures including diagnostic techniques such as questioning, pulse evaluation, palpation on a variety of areas of my body, observation, range of motion, muscle and orthopedic testing, modes of manual stimulation; cupping and/or moxibustion; the prescription of herbal and homeopathic medicines as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle recommendations.  

I understand I have opportunities to discuss with my practitioners and/or with other clinic personnel the nature and purpose of acupuncture and other TCM procedures.  Although I am aware that acupuncture and the other procedures used in TCM have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.  

I understand and am informed that, as in the practice of conventional Western medicine, in the practice of TCM there are some risks to treatment.  I understand that although these risks are unlikely to occur, they are possible.  I understand that these risks include, but are not limited to:  bleeding, bruising, pain or other strong sensation at the location of where a needle is inserted, or where cupping or herbal application is made to the skin, or radiating from those locations; nerve pain, burns, aggravation of current symptoms, appearance of new symptoms and general aches.  Other uncommon but possible risks include pneumothorax (punctured lung), puncture of other organs, sprains, strains, dislocation, fractures, disc injuries and strokes.  I do not expect the practitioners to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioners to exercise such judgement, during the course of my treatment, as the practitioner feels at the time, based on the facts then known, to be in my best interest. 

I understand that acupuncture and TCM treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment.  If there is reasonable cause to believe that treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol, or appears to be overly medicated, then a treatment may not be performed at that time.  The patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment. 

I have read, or have had read to me, this informed consent form.  I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures and conditions of treatment.  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 the As You Are Acupuncture clinic.

Patient/Guardian Signature:

 

July 29, 2021

 

Office Policies

I Agree
Cancellation Policy and Late Arrivals (15 minutes late or more) - Treatments are by appointment, although walk-ins are often able to be accommodated. Life happens! If you find that you need to cancel an appointment, please call or email us as soon as you are aware you need to. We reserve the right to charge 75% of our fee if you cancel within 24 hours of your appointment. If the appointment is rescheduled for another time that same day and we can accommodate it, the fee is waived. You will receive a reminder text and email. Payment is taken upon booking.

I Agree
Payment for Services Rendered - Payment is due at the time of booking and may be paid with a medical savings account card, flexible spending account card, health savings account card & all major credit cards. We are happy to provide you with a superbill so you may file with your insurance carrier. 

​PATIENT SIGNATURE:

July 29, 2021

 

Notice of Privacy Policies 

Our office is dedicated to providing service with respect for human dignity.  Protecting your privacy and healthcare information is fundamental in the course of our relationship.  This notice will remain in effect until it is replaced or amended by changes in law. 

We gather personal information and health information in several ways:

  • Information we receive from you.
  • Information we receive from other healthcare providers.
  • Information we receive from third party payers. 

This information is used for treatment, payment and healthcare operations.  You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for the treatment, payment, and healthcare operations.  We will only use and/or disclose your protected health information when the law allows us to do so.  Any other use and disclosures will be made only with your authorization and, in those instances; you have the right to revoke that authorization.  And if so, that authorization would be honored, where legal to do so, from that date forward. 

Treatment: For example, from time to time, our practitioners may decide that it is medically necessary to refer you to a specialist for additional care.  That practitioner will need your medical information in order to be able to treat you and that is why we send out your records.

Payment:  Many of our patients utilize medical insurance that actually pays for their treatment.  The insurers require your medical information to know how to pay us or your care and that is why we send out your records.

Health Care Operations:  We are allowed to disclose your medical information if that is necessary for our office to function efficiently.  There are also times when we may need the help of a special vendor, such as a medical billing specialist, and we would then send your records to that vendor in order for us to carry on our business. 

You may specifically authorize us to use protected health information for any purpose or to disclose our health information by submitting the authorization in writing.  Such disclosures will be made to any personal representation you choose to have your protected health information. 

This office has many practitioners. We reserve the right to share your file information within the confines of the professional and academic practices. 

Marketing

This office will not use your health information for marketing communications without your written authorization.  This office may send birthday cards, holiday cards, thank you cards, newsletters and appointment reminders, by calls, postcards or letters.  

Disclosure

This office may use or disclose your Protected Health Information when required by law.  This includes but is 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.  Exceptions are:  1) psychotherapy notes; 2) information we gather in preparation of an administrative action or proceeding; 3) data that is subject to certain provisions of the Clinical Laboratory Improvements Act.  We may deny your request (in writing) under certain limited circumstances.  Generally, if we agree to provide you with a copy of your records, we will do so within 15 days after you ask for it.  We may charge you a reasonable, cost-based fee for the records.
  • Upon written request you have the right to receive a list of items this office disclosed about your healthcare information.  We are required to give you that data except for any use or disclosure:  1) for treatment, payment and/or health care operations; 2) made with your authorization; 3) that we make to you; 4) for any national security or intelligence purposes; 5) made before July 1, 2020; or 6) that does not require your authorization.  We will provide this date for you (generally within 60 days) at no charge once each year, but after that, we will require that you pay a reasonable fee-based charge for the information.
  • You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information.  You may ask that we limit the use and disclosure of your protected health information; we are not required to accept your request.  If we do agree, however, we will do as you wish except in an emergency.  You may submit your request to us in writing and tell us:  1) what information you want us to limit  2) how you want us to limit that data and 3) to whom we are to limit the access to this data.  
  • You have the right to request that we amend your Protected Health Information; the request must be in writing.  We have the right to deny that request if you ask about medical information that 1) was not created by any of our practitioners; 2) the information is not part of the medical or billing records; 3) is not part of the records you may access or 4) the medical information is accurate and complete.  We may ask that you tell us, in writing, why you want us to amend your medical information.  Generally, we must act upon your request within 60 days after receipt of your request.  If we agree to your request, we must make the appropriate amendment and follow the law regarding how and whom we inform about this amendment.  If we do not agree, then we will tell you our reasons.  You then have additional rights, including an appeal (by someone who did not participate in the decision not to allow you to amend your record) and you have the right to submit a written statement of disagreement.
  • You have a right to receive all notices in writing.
  • You have the right to receive confidential communication by alternative means or at alternative locations.  Please make this request in writing to us.  We will agree, so long as your request is reasonable, but you must tell us how to communicate with you and you must give us a complete address or contact information.

If you have questions, complaints or want more information contact:        

NAME:  Nicole Fillion-Robin, LAc
PHONE NUMBER: 512-270-1664
EMAIL: nicole@asyouareacu.com

You may also choose to send a written complaint to the U.S. Department of Health and Human Services.

This notice is effective as of May 25, 2020.  From time to time, we may revise our Notice.  If we do, we will post the most current version in our office, and you make ask for a copy of the Notice at any time.

 

HIPAA Acknowledgement and Appointment Reminders 

I acknowledge that I have been provided access to the As You Are Acupuncture  “Notice of Privacy Practices.”  I understand that I have a right to review the “Notice of Privacy Practices” prior to signing this document.   

I understand that As You Are Acupuncture staff members may need to contact me with appointment reminders or information related to my treatments.  If this contact is to be made by phone, and I am not at home, a message will be left on my answering machine or with anyone who answers the phone.   

I also understand that my clinical information may be used for educational and/or research purposes by As You Are Acupuncture or individuals authorized by As You Are Acupuncture.  All information that can identify me personally will be removed.   

By signing this form, I am giving As You Are Acupuncture authorization to contact me and am giving my informed consent to utilize my information for research and educational purposes.  I acknowledge that all information  discussed during the assessment and treatment at As You Are Acupuncture clinics will be held confidential except in the instance where my safety or the safety of others may be at risk.  

I hereby authorize As You Are Acupuncture the use or disclosure of my individually identifiable health information to the party(s) described on the following page under "Authorization of Personal Health Information."  I understand this authorization is voluntary.  I understand if the party(s) authorized to receive my information is/are not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.

I will provide, on the next page information on any party(s) authorized to receive my information.

 

Patient/Guardian Signature:

July 29, 2021

 

Arbitration Agreement

Article 1:  Agreement to Arbitrate:  It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings.  Both parties to this contract, entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. 

Article 2:  All Claims Must be Arbitrated:  It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration.  It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium.  This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim.  This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.  All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.  

Article 3:  Procedures and Applicable Law:  A demand for arbitration must be communicated in writing to all parties.  Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter  The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non‐economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. 

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement.

Article 6: Retroactive Effect: If a patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) the patient should initial here.


Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement.

Patient/Guardian Signature:

July 29, 2021

First Patient's Name

First Name*

Last Name*
First Patient's Date of Birth*
First Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Authorization for Release of Personal Health Information.

I hereby authorize As You Are Acupuncture the use or disclosure of my individually identifiable health information to the party(s) described below.


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Notification Form Regarding Evaluation of Patient by Physician 

In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, We are required to have you respond affirmatively to at least one of 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 section 183.10(a)(11) of this title and section 205.302 V.A.C>S article 4495b, governing the practice of acupuncture)


I am notifying As You Are Acupuncture of the following: 

I have been evaluated by a physician, dentist, or nurse practitioner, for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist.*
Yes
No
I have received a referral from my chiropractor within the last 30 days for acupuncture*
Yes
No

The date of the referral is:

The most recent date of treatment prior to acupuncture treatment is:

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.

AND/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

Should I return for treatment for any condition other than my original condition(s) treated at this clinic, I understand it is my responsibility to be evaluated by a physician prior to acupuncture.



Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well. Allow As You Are Acupuncture to use photos or videos of my treatments & progress?*
Yes
No
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!