acupuncture-forms - Alt Therapies Center

Case History Information

Name

Birthdate:

Age

Address

Social Security #

City

Occupation

State

Zip

Employer

Phone(Day)

Employement Address

Phone(Evening)

City

Your Doctors Name

State

Specialty

Work Phone

Your Doctor's Phone

Diagonosis by your Doctor

Present Complaints

Referred By

My Pain Now is

Minimal

Slight

Moderate

Severe

CONSENT FOR ACUPUNCTURE TREATMENT AND CARE

I, the undersigned, do hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures. The methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Massage), Chinese or Western Herbal Medicine, and nutritional counseling.

I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few days. There may be some bruising after cupping. The herbs and nutritional supplements which may be recommended are traditionally considered safe in the practice of Herbal Medicine.

I wish to rely on the acupuncturist to exercise judgment during the course of the treatment, which the acupuncturist feels at the time is in my best interests.

By signing below, I agree to the above-named procedures. I intend this consent to cover the entire course of treatment for my present condition(s).

Patient's Signature:

Date:

FORM TO BE COMPLETED BY PATIENT

NOTIFYING THE ACUPUNCTURIST OF WHETHER PATIENT HAS BEEN
EVALUATED BY A PHYSICIAN AND OTHER INFORMATION

(Pursuant to the requirement of Section 6.11, subsections (b) through (d),
V.A.C.S., article 4495b, governing the practice of acupuncture)

I (Patient’s name) , am notifying the acupuncturist Sucheta Dagli Shah of the following:

Have you been evaluated by a physician or dentist for the condition being treated within six months before the acupuncture was performed?

Yes

I recognize that I should be evaluated by a physician for the condition being treated by the acupuncturist.

(Patient’s initials)

Date

Have you received a referral from your chiropractor within the last 30 days for acupuncture?

Yes

After being referred by a Chiropractor, if after 30 days or 20 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 to follow this advice.

Signature

Date

Alt Therapies Center
Sucheta Dagli Shah LAC, MSOM

Accupunture form

Case History Information

Please Answer the Following Questions:

Please Indicate Your Preferred Payment Method:

CONSENT FOR ACUPUNCTURE TREATMENT AND CARE

Case History Information

Family Diseases:

Lungs:

Hormonal Problems:

Substance Abuse

Infectious Diseases / Parasites:

Bad Reaction to Any Drug or Vaccination?

FORM TO BE COMPLETED BY PATIENT

NOTIFYING THE ACUPUNCTURIST OF WHETHER PATIENT HAS BEEN
EVALUATED BY A PHYSICIAN AND OTHER INFORMATION

“ The leading Acupuncture and Homeopathy Clinic in Texas.”

Accupunture form

Case History Information

Please Answer the Following Questions:

Please Indicate Your Preferred Payment Method:

CONSENT FOR ACUPUNCTURE TREATMENT AND CARE

Case History Information

Family Diseases:

Lungs:

Hormonal Problems:

Substance Abuse

Infectious Diseases / Parasites:

Bad Reaction to Any Drug or Vaccination?

FORM TO BE COMPLETED BY PATIENT

NOTIFYING THE ACUPUNCTURIST OF WHETHER PATIENT HAS BEEN EVALUATED BY A PHYSICIAN AND OTHER INFORMATION

NOTIFYING THE ACUPUNCTURIST OF WHETHER PATIENT HAS BEEN
EVALUATED BY A PHYSICIAN AND OTHER INFORMATION