Scott Bray DOM, L.Ac Natural, Safe & Effective Alternative Medicine Legacy Place Suite 109 10967 Lake Underhill Rd. Orlando FL 32825 407-658-1341 Home Scott Bray DOM, L.Ac Workshops Events T’ai Chi & Chin Na Gallery Videos Blog Patient Form Accessibility Contact Us Patient Forms New Patient Intake Form Step 1 of 8 0% 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.Name* First Middle Inital Last Your Email* This field is hidden when viewing the formToday's Date Month Day Year Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Cell PhoneHome PhoneWork PhonePrefered Contact Number*Cell NumberHome NumberWork NumberBirthday Date* Month Day Year MARITAL STATUS*Are you Employed?* No Yes EMPLOYMENT - OCCUPATIONHAVE YOU HAD AN AUTO ACCIDENT WITHIN THE LAST TWO YEARS?NoYesIF YES, PLEASE GIVE THE DATE OF THE ACCIDENT Month Day Year ARE YOU EXPECTING OR THERE IS A POSSIBILITY OF PREGNANCY?NoYesWHERE DID YOU FIRST LEARN ABOUT THE ACUPUNCTURE OFFICE OF SCOTT BRAY A.P.?MAJOR MEDICAL COMPLAINT:*Date of Onset Symptoms* Month Day Year SURGICAL HISTORY:CURRENT MEDICATIONS:Do you have insurance that covers Acupuncture?* No Yes Are you the Primary Policy Holder?* Yes No This field is hidden when viewing the formFull Name of the Policy HolderThis field is hidden when viewing the formDate of Birth of the Main Policy Holder Month Day Year PRIMARY INSURANCE:HEALTHMEDICAREWORK. COMPAUTOInsurance InformationInsurance Company NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Providers PhoneFax NumberNAME OF POLICY HOLDERMember IDGroup NumberClaim NumberSECONDARY/SUPPLEMENTAL INSURANCE:Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Providers PhoneFax NumberNAME OF POLICY HOLDER:Member IDGroup NumberClaim Number Patient ProfileName* First Middle Inital Last Date 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 ElementHearing Loss0123Dizziness0123Lower Back Pain/Neck Pain0123Sinus Congestion0123Edema0123Darkness under the eyes0123Emotional instability0123Aversion to cold0123Hair thinning or loss0123Pre-mature aging0123Frequent urination0123Kidney stones0123Perspire very easily0123Weakness of the Legs/Knees0123Asthmatic Cough0123Rapid Weight Change0123Loose teeth0123Reduced sexual energy0123Thyroid Problems0123Diabetes0123Wood ElementHeadache0123Migraines0123Ringing in the ears0123Poor eyesight0123Eye infections0123Dry eyes0123Eczema0123Shingles0123Herpes Simplex0123Warts0123Nervousness0123Convulsions/Spasms0123Irritability0123Constipation0123Hemorrhoids0123Hepatitis0123Irregular Menstruation0123Painful Menstruation0123Ulcer0123Vomiting0123Gallstones0123Indecisiveness0123Fullness below ribs0123Shoulder/neck tension0123Insomnia 11pm-3am0123Fire ElementDry Scalp0123Skin eruptions, rashes0123Cysts, tumors0123Ear infections0123Sore throat, tonsillitis0123Lymphatic swelling0123Hot palms and soles0123Heart palpitations0123Aversion to heat0123Bitter taste in mouth0123Gum problems0123Nose bleed0123Facial redness0123Itching/burning skin0123Hot hands/ feet0123Thirst0123Dark urine0123Nightsweats0123Earth ElementIndigestion0123Flatulence0123Food Allergy0123Stomach ache/ulcer0123Diarrhea0123Anemia0123Hallitosis0123Mouth sores0123Heartburn0123Strong appetite0123Weak appetite0123Nausea0123Abdominal bloating0123Low body weight0123Metal ElementBronchitis0123Asthma0123Shallow breathing0123Cough0123Sinus congestion0123Nasal infections0123OtherFatigue0123Arthralgia0123Sciatica / nerve pain0123Cold hands/ feet0123Tendonitis0123Bursitis0123Pain (please describe)Other Comments ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESThis 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 PracticesI acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice.Signature*First Name - Middle/Inital - Last Name*Date of Birth* Month Day Year Financial PolicyThank 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 INSURANCEUpon 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*Select OneI do not have insurance to cover your fees.I have insurance coverage and would like you to file my claim.OTHER PAYMENT:*Select OneCash, Check or CreditMISSED APPOINTMENTSUnless 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* Month Day Year HEALTH PRIVACY & EMERGENCY CONTACTSPlease 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 PhonePlease indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”:Yes or No*NoYesPlease 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 numberPhone*Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail?Yes or No*YesNoPATIENT NAME ( if under 18 years guardian required)*PATIENT/GUARDIAN SIGNATURE*Date* Month Day Year What to Expect1. 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)*Select One . . .Symptomatic TreatmentCorrective Treatment5. 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* Month Day Year 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 Month Day Year 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 Month Day Year SignatureEmailThis field is for validation purposes and should be left unchanged.
