Patient Forms

New Patient Intake Form

Step 1 of 8

NOTE: Many factors must be considered in designing a complete health building program. Treating the whole person requires attention to all symptoms and conditions. Often minor symptoms are clues to delicate biochemical or somatic imbalances. Therefore, please complete all of this questionnaire as carefully and as completely as you can. This is a confidential record of your medical history and will be kept in this office. Information contained in this form will not be released to any person except when you have authorized us to do so.
First Name - Middle/Inital - Last Name*
Your Email*
Today's Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email
Cell Phone
Home Phone
Work Phone
Prefered Contact Number*
Birthday Date*
MM
DD
YYYY
MARITAL STATUS*
Are you Employed?*
- No
- Yes
EMPLOYMENT - OCCUPATION
HAVE YOU HAD AN AUTO ACCIDENT WITHIN THE LAST TWO YEARS?
IF YES, PLEASE GIVE THE DATE OF THE ACCIDENT
Date Format: MM slash DD slash YYYY
ARE YOU EXPECTING OR THERE IS A POSSIBILITY OF PREGNANCY?
WHERE DID YOU FIRST LEARN ABOUT THE ACUPUNCTURE OFFICE OF SCOTT BRAY A.P.?
MAJOR MEDICAL COMPLAINT:*
Date of Onset Symptoms*
Date Format: MM slash DD slash YYYY
SURGICAL HISTORY:
CURRENT MEDICATIONS:
Do you have insurance that covers Acupuncture?*
- No
- Yes
Are you the Primary Policy Holder?*
- Yes
- No
Full Name of the Policy Holder
Date of Birth of the Main Policy Holder
Date Format: MM slash DD slash YYYY
PRIMARY INSURANCE:
Insurance Information
Insurance Company Name
Address
Street Address Address Line 2 City State ZIP Code
Providers Phone
Fax Number
NAME OF POLICY HOLDER
Member ID
Group Number
Claim Number
SECONDARY/SUPPLEMENTAL INSURANCE:
Address
Street Address Address Line 2 City State ZIP Code
Providers Phone
Fax Number
NAME OF POLICY HOLDER:
Member ID
Group Number
Claim Number

Patient Profile
Name*
First Last
Date
Date Format: MM slash DD slash YYYY
It is very important in Chinese Medicine to know how long a patient has experienced his/her symptoms. It is essential to indicate time on the symptoms. Please indicate with number one check (1) any conditions that you sometimes experience; use number two (2) for those which often occur and number three (3) for symptoms that are a major concern.
Water Element
Hearing Loss
Dizziness
Lower Back Pain/Neck Pain
Sinus Congestion
Edema
Darkness under the eyes
Emotional instability
Aversion to cold
Hair thinning or loss
Pre-mature aging
Frequent urination
Kidney stones
Perspire very easily
Weakness of the Legs/Knees
Asthmatic Cough
Rapid Weight Change
Loose teeth
Reduced sexual energy
Thyroid Problems
Diabetes
Wood Element
Headache
Migraines
Ringing in the ears
Poor eyesight
Eye infections
Dry eyes
Eczema
Shingles
Herpes Simplex
Warts
Nervousness
Convulsions/Spasms
Irritability
Constipation
Hemorrhoids
Hepatitis
Irregular Menstruation
Painful Menstruation
Ulcer
Vomiting
Gallstones
Indecisiveness
Fullness below ribs
Shoulder/neck tension
Insomnia 11pm-3am
Fire Element
Dry Scalp
Skin eruptions, rashes
Cysts, tumors
Ear infections
Sore throat, tonsillitis
Lymphatic swelling
Hot palms and soles
Heart palpitations
Aversion to heat
Bitter taste in mouth
Gum problems
Nose bleed
Facial redness
Itching/burning skin
Hot hands/ feet
Thirst
Dark urine
Nightsweats
Earth Element
Indigestion
Flatulence
Food Allergy
Stomach ache/ulcer
Diarrhea
Anemia
Hallitosis
Mouth sores
Heartburn
Strong appetite
Weak appetite
Nausea
Abdominal bloating
Low body weight
Metal Element
Bronchitis
Asthma
Shallow breathing
Cough
Sinus congestion
Nasal infections
Other
Fatigue
Arthralgia
Sciatica / nerve pain
Cold hands/ feet
Tendonitis
Bursitis
Pain (please describe)
Other Comments

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
This notice summarizes how health data about you may be used and shared and how can get access to this data. IMPORTANT NOTE: This does not include all of the details about our privacy policy. For more details, please read the NOTICE OF PRIVACY PRACTICES that your practitioner has provided you.
I. How we may use and share health data about you:
a) Treatment – To give you medical treatment or other types of health services. b) Payment- To bill you or a third party for payment for services provided to you. c) Health Care Operations- For our own operations such as quality control, compliance monitoring, audit, etc.
II. Disclosures where we do not have to give you a chance to agree or object:
a) To you. - b) As required by federal, state, or local law. - c) If child abuse or neglect is suspected. - d) Public health risks (for public health activities to prevent and control spread of disease). - e) Lawsuits and disputes (in response to a court or administrative order). - f) Law enforcement ( to help law enforcement officials respond to criminal activities). - g) Coroners, medical examiners and funeral directors. - h) Organ or tissue donation facilities if you are an organ donor. - i) To avert a threat to an individual or to public health safety.
III. Disclosures where we have to give you a chance to agree or object:
a) Patient directories – You can decide what health data, if any, you want to be listed in patient directories. - b) Persons involved in your care or payment for your care – We may share your health data with a family member, a close friend, or other person that you have named as being involved with your health care.
IV. Other uses of health data: Other uses not covered by this notice or the laws that apply to us will be made only with your written consent.
V. You have the following rights relating to the health data we keep about you:
a) Right to inspect your health record and to receive copy of your health record upon request - b) Right to amend information in your health record you believe is inaccurate or incomplete - c) Right to know to whom we have disclosed your health information - d) Right to ask for limits on the health information data we give out about you - e) Right to receive communication from us about your health information in alternate ways - f) Right to a paper copy of the complete Notice of Privacy Practices
I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice.
Signature*
First Name - Middle/Inital - Last Name*
Date of Birth*
MM
DD
YYYY

Financial Policy
Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
All patients must complete our "Patient Questionnaire" before seeing the doctor.
FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA or MASTERCARD.
REGARDING INSURANCE
Upon schedling your first appointment we will verify coverage for acupuncture benefits. If for any reason we are not able to verify coverage prior to your treatment, you will be charged for services rendered until verification is obtained. Our fees are determined by the complexity of the particular case and the different services used during treatment. Any balance due on your treatments is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you bring in all insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. But in the case we are a contracted provider by your insurance we will gladly accept the prearranged payment as full payment minus co-pay. Additionally in signing this document you authorize the release of any information to any insurance company, adjustor or attorney that will assist in the payment of your claim.
USUAL AND CUSTOMARY RATES (URC)
Our practice is committed to providing the best treatment possible for our patients. We charge what is usual and customary for our area. Please be aware, at times, some or all of the services provided, may be “non-covered” services and not considered reasonable and necessary under the Medicare program and/or by other medical insurance. You are responsible for payment in full regardless of any insurance company’s arbitrary determination of usual and customary rates.
First Name - Middle/Inital - Last Name*
Payment Options*
OTHER PAYMENT:*
MISSED APPOINTMENTS
Unless canceled at least 24 hours in advance, our policy is to charge $30.00 for missed appointments. Your treatments will be more effective if you follow your doctor's guidelines and stick to your treatment schedule. Please realize that we are blocking one hour to hour and a half of our office time for your treatment. Our goal with this agreement is to create awareness of the importance of following the suggested course of treatment and to eliminate “no shows” or last minute cancellations.
Thank you for understanding our financial Policy. Please let us know if you have any questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy.
Signature of Patient or Responsible Party*
Date*
Date Format: MM slash DD slash YYYY

HEALTH PRIVACY & EMERGENCY CONTACTS
Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care):
You may share my information with:*
First Last
You may share my information with:
First Last
Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY:
Emergency Contact :*
First Last
Phone*
Emergency Contact :
First Last
Phone
Please indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”:
Yes or No*
Please print the telephone number where you want to receive calls about your appointments, lab and x-ray results, or other health care information if other than your home phone number
Phone*
Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail?
Yes or No*
PATIENT NAME ( if under 18 years guardian required)*
PATIENT/GUARDIAN SIGNATURE*
Date*
Date Format: MM slash DD slash YYYY

What to Expect
1. New patients are requested to fill out a Patient Profile and Questionnaire.
2. Consultation with the Acupuncturist to discuss your health issues and what may be the root of the problem.
3. A thorough examination will be given to determine the cause.
Name*
First Last
4. Will you be seeking: (Select one)*
5. The Acupuncturist will recommend if any further testing is considered necessary.
6. At this point the Acupuncturist will give a detailed explanation of treatment, including the number of treatments and cost.
7. Treatment will begin.
8. After condition has been stabilized, the Acupuncturist will make suggestions to help you from incurring any future problems and to maintain your good health.
Important Note:
Be aware that we are setting aside an hour of our time for your treatment. It is IMPERTATIVE that you keep your appointment or give a 24 hours canelation notice.
Date*
Date Format: MM slash DD slash YYYY

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as backup for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a mom Dor of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the heros. I have been informed that acupuncture is a generally safo method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bums and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a dean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although 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, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, 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.
Date
Date Format: MM slash DD slash YYYY
Signature

Name
First Last
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 wore 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, by 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 binds all parties as to all claims, including claims arising out of or relating to treatment or services provided by the healthcare 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 healthcare 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 healthcare 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 healthcare 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 have 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.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. Effective as of 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. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Date
Date Format: MM slash DD slash YYYY
Signature
Email
This field is for validation purposes and should be left unchanged.

Scott Bray DOM, L.Ac

Patient Forms

New Patient Intake Form

Step 1 of 8

Insurance Information

SECONDARY/SUPPLEMENTAL INSURANCE:

Patient Profile

Water Element

Wood Element

Fire Element

Earth Element

Metal Element

Other

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Financial Policy

REGARDING INSURANCE

USUAL AND CUSTOMARY RATES (URC)

MISSED APPOINTMENTS

HEALTH PRIVACY & EMERGENCY CONTACTS

What to Expect

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