Patient Intake Form | Georgina Castle, DACM, MPH

Personal Information

First Name

Last Name

Birthdate

Sex

Male Female

Address

City

State

Zip

Email

Primary Language

Cell Phone

Other Phone

Employer

Occupation

Current Condition

Are you under the care of a physician?

No Yes

Please describe your current health problem(s)

How and When it began

What treatment have you received for the above conditions(s)?

Surgery Medications Physical Therapy Chiropractic Massage Injections Other

Is this work related?

Yes No

Progress So Far

Pain & Symptoms

Pain Level (0 - 10)

0

No Pain Unbearable

interference with Daily Activities (0 - 10)

0

None Unable to carry on

Symptom Frequency

General Health Condition

Excellent Very Good Good Fair Poor

Medical History

Check all that apply to you

Tobacco Use

No Yes

List any medications you are taking:

If the family member has had any of the following, please mark the box and explain the relationship:

Cancer

Heart Disease

Hypertension

Lupus

Other

Terms and Conditions of Service

Are you the patient?

Yes No

Admission and Medical Services Agreement:

The patient or the patient's representative consents to the admission of the patient to Georgina Castle, DACM, MPH if this is deemed necessary for the care of the patients. All the terms and conditions hereof also apply to such admissions.

Medical Consent:

I have read and fully understand that the patient accepts the full responsibility to follow up the medical advice given by Georgina Castle, DACM, MPH the patient or the patient's representative consents to the treatment procedures and its results and repercussions thereof and accepts arbitration if deemed necessary.

Release of Information:

Georgina Castle, DACM, MPH is authorized to furnish from the patients records necessary information to the referring physician, if any, and to others to the extent required in connection with a claim for aid, insurance, or medical assistance to which the patient may be entitled. The patient or his/her medical records from previous medical history rendered by other physicians or medical centers.

Financial Agreement:

The patient or patient's representative shall pay Georgina Castle, DACM, MPH services rendered in accordance with the regular rates and terms by Georgina Castle, DACM, MPH. When this agreement is executed by the patient or the patient's representative or a financial guarantor, all shall be jointly and individually liable for the patient. Should accounts be referred to an attorney or collection agency, reasonable attorney's fees and collections expenses incurred shall be payable in addition to the other amounts due.

48-Hour Cancellation and Missed Appointment Policy:

Please let us know if you need to cancel or reschedule an appointment. Failure to provide 48-hour notice or failure to show will result in your account being charged for the visitation at our standard fee of $95. Your insurance carrier is not responsible for this fee.

Georgina Castle, DACM, MPH and patient or the patient's representative hereby enter into this agreement. The patient or the patient's representative certifies that he/she has read and accepted the "Terms and Conditions of Service."

Signature of Patient

Click to Sign

Date

Signature of Representative

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Date

Acknowledgement of Receipt of Notice of Privacy Practices:

I, do hereby acknowledge receipt of a copy of the Notice of Privacy Practices, Polices, and Procedures from Georgina Castle, DACM, MPH.

Signature of Patient

Click to Sign

Date

Signature of Representative

Click to Sign

Date

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 California and federal law, and not by a lawsuit or resort to court process except as California and federal law provide for judicial review of arbitration proceedings...

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, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration...

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...

Article 4: General Provision:

All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding...

Article 5: Revocation:

This agreement may be revoked by written notice delivered to the healthcare 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), please select Yes and initial below.

Yes No

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.

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.

Patient Name (print)

Signature

Click to Sign

Date

Parent or Guardian (print)

Signature

Click to Sign

Date

Office Name

Signature

Date

Acupuncture Informed Consent to Treat

I understand that I am the decision maker for my health care. Part of this office's role is to provide me with information to assist me in making informed choices...

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me...

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage)...

I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment...

I understand that while this document describes the major risks of treatment, other side effects and risks may occur...

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment...

I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently...

I understand that there are treatment options available for my condition other than acupuncture procedures...

By voluntarily signing below, I confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits...

Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Patient Name:

Acupuncturist Name:

Patient Signature (X)

Click to Sign

Date

(Or Patient Representative) Indicate relationship if signing for patient

Castle Acupuncture-New Patient Intake Form

Personal Information

Current Condition

Pain & Symptoms

Medical History

Terms and Conditions of Service

Admission and Medical Services Agreement:

Medical Consent:

Release of Information:

Financial Agreement:

48-Hour Cancellation and Missed Appointment Policy:

Acknowledgement of Receipt of Notice of Privacy Practices:

Arbitration Agreement

Article 1: Agreement to Arbitrate:

Article 2: All Claims Must be Arbitrated:

Article 3: Procedures and Applicable Law:

Article 4: General Provision:

Article 5: Revocation:

Article 6: Retroactive Effect:

Acupuncture Informed Consent to Treat

Submission Successful!

Personal Information

Current Condition

Pain & Symptoms

Medical History

Terms and Conditions of Service

Admission and Medical Services Agreement:

Medical Consent:

Release of Information:

Financial Agreement:

48-Hour Cancellation and Missed Appointment Policy:

Acknowledgement of Receipt of Notice of Privacy Practices:

Arbitration Agreement

Article 1: Agreement to Arbitrate:

Article 2: All Claims Must be Arbitrated:

Article 3: Procedures and Applicable Law:

Article 4: General Provision:

Article 5: Revocation:

Article 6: Retroactive Effect:

Acupuncture Informed Consent to Treat

Submission Successful!

Sign Here