243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com
Confidential Health Intake Form
Name________________________________________ Date______________________
Address__________________________City______________State_______Zip_______
Phone: Home (
)
Cell (
)
Work (
) ________
Which phone number would it be all right to leave you messages? _________________
Date of Birth:
________________________
Email address:___________________________________________________________
May we email you with announcements? Yes
No
Emergency Information
Emergency Contact:
Relationship:___________________
Phone #(s):______________________________________________________________
Your Primary Health Care Provider__________________________________________
Name
Phone ( )_____________________
Address_________________________________________________________________
I give Burien Natural Health Center permission to consult with my treating health care
provider regarding my health and treatment. Initials__________ Date________
Current Health Information
Please list ALL of your current symptoms that have brought you in today:____________
________________________________________________________________________
________________________________________________________________________
243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com
Check All Current and Previous Conditions:
General
Nervous System
Allergies
current past
current past
current past
headaches
head injuries
scents/oils, etc
pain
dizziness
detergents
Where?_________
numbness, tingling
other
sleep disturbances
sciatica, shooting pain
fatigue
chronic pain
fever, infections
depression
bowel issues
sinus issues
other:________________
gas, bloating
other______________
Skin Conditions
Digestive System
other_______
Respiratory, Cardiovascular Endocrine System
rashes
heart disease
thyroid issues
herpes zoster
blood clots
diabetes
fungal infections
stroke
other___________
high/low blood pressure
Reproductive
irregular heart beat
Pregnancy
poor circulation
irreg. menses
arthritis
edema
cysts, fibroids
osteoporosis
varicose veins
other_______
scoliosis
chest pain
broken bones
asthma
Cancer/Tumors
disc issues
lung issues
benign
Muscles & Joints
TMJ, jaw pain
other____________
pneumonia/pleurisy
other______________
243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com
malignant
other_______
Policies and Authorizations
Payment Policy: YOU ARE ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF YOUR
ACCOUNT.
Patients with insurance: If your private insurance policy provides benefits for acupuncture we will be happy to
submit a claim to them on your behalf. You are expected to pay your estimated portion at the time services are
rendered. Your estimated portion will be calculated by the benefit information we receive from your insurance
company. A benefit quote is not a guarantee of payment. Patients who are treating on worker’s compensation
or motor vehicle collision claims are required to get us the proper insurance information and referrals:
Motor Vehicle Collision: Your auto insurance company will pay for necessary acupuncture if you had “PIP”
(Personal Injury Protection) coverage included in your policy at the time of the collision. You must file a claim
with your auto insurance company, complete and return a PIP application to them before they will issue any
payment towards your account.
Clients when insurance doesn’t apply: We offer a time of service discount for patients with limited insurance
benefits or for patients with no insurance coverage at all for massage and acupuncture. Ask for details.
____________patient initials
Cancelation Policy
We would like to stress the importance of receiving acupuncture regularly, especially for the rehabilitation of
an injury. If you receive treatments on schedule, the success and benefits will be greatly increased and
recovery time will be quicker. In respect to you and us, we will need twenty-four (24) hour notice of
cancellation of appointments (except in emergencies). If we are not notified in a timely manner, you may be
charged a cancelation fee of $35 and treatment will not resume until payment is received. By letting us know
in advance we can fill your spot with another client waiting for an appointment. IF THREE OR MORE
APPOINTMENTS ARE LATE CANCELLED OR MISSED WE MAY CANCEL ALL STANDING
APPOINTMENTS UNTIL PAYMENT IS RECEIVED. _______________ patient initials
Right of Refusal
We reserve the right to refuse service to anyone at anytime without explanation.
Notice of Privacy Practices Acknowledgement (HIPAA)
We keep a record of the health care services we provide to you. You may ask to see and copy that record. You
may ask to correct that record. We will not disclose your records to others unless you direct us to do so or
unless the law authorizes or requires us to do so. You may also see your record or get more information about
it by contacting our clinic. Our notice of privacy practices describes in more detail how your health
information may be used and disclosed and how you can access your information. A copy of the notice is
available upon request.
_____________ patient initials
Authorization to Bill Insurance
In consideration of your undertaking to care for me, I agree to the following:
1.
You are authorized to release any information you deem appropriate concerning my physical condition to
any insurance company, attorney or adjuster to process any claim for reimbursement of charges incurred.
2.
I authorize the direct payment to you of any sum I now or hereafter owe you, by my attorney, out of the
proceeds of any settlement of my case, and/or by any insurance company obligated to make payment to
me or you based in whole or in part upon the charges made for your services.
243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com
3.
In the event any insurance company obligated by contractual agreement to make payment to me or to you
for the charges made for your services refuses to make such payment upon demand by you, I hereby
assign and transfer to you the cause of action that exists in my favor against any such company and
authorize you to prosecute said action in my name as you see fit and further authorize you to
compromise, settle or otherwise resolve said claim as you see fit. I understand that whatever amounts you
do not collect from insurance company’s proceeds, whether it is all or part of what is due, I personally
owe and agree to pay to you.
4.
In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in the
state of Washington.
5.
I further agree that this authorization and assignment is irrevocable and ongoing until all monies owed
are paid in full.
6.
This authorization for assignment will be in continual effect until revoked by both parties.
*I have read and I understand the above content, including payment policy, cancelation policy, right of
refusal, notice of privacy practices and authorization to bill insurance. I agree to comply with all that is
stated above.
____________________________
Date:____________
Patient Name
_____________________________________________
Patient Signature (If minor, parent or guardian must sign)
Consent To Treatment
By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or
substances from the Oriental Materia Medica by a licensed acupuncturist at Burien Natural
Health Center. I understand that acupuncturists practicing in the state of Washington are not
primary care providers and that regular primary care by a licensed physician is an important
choice that is strongly recommended by this clinic’s practitioners.
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of
needles through the skin or by the application of heat to the skin (or both) at certain points on or
near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or
prevent pain perception, and to normalize the body’s physiological functions. I am aware that
certain adverse side effects may result. These could include, but are not limited to: local bruising,
minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing
prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are
given to me and that I am free to stop acupuncture treatment at any time.
Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is
a risk of burning or scarring from its use. I understand that I may refuse this therapy.
Chinese Herbs: I understand that substances from the Oriental Materia Medica may be
recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain
perception, and to normalize the body’s physiological functions. I understand that I am not
required to take these substances but must follow the directions for administration and dosage if I
243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com
do decide to take them. I am aware that certain adverse side effects may result from taking these
substances. These could include, but are not limited to: changes in bowel movement, abdominal
pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment.
Should I experience any problems, which I associate with these substances, I should suspend
taking them and call Burien Natural Health Center as soon as possible.
Acupressure/Tui-Na Massage: I understand that I may also be given acupressure/tui-na
massage as part of my treatment to modify or prevent pain perception and to normalize the
body’s physiological functions. I am aware that certain adverse side effects may result from this
treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the
possible aggravation of symptoms existing prior to treatment. I understand that I may stop the
treatment if it is too uncomfortable.
Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture
administered with the acupuncture. I am aware that certain adverse side effects may result. These
may include, but are not limited to: electrical shock, pain or discomfort, and the possible
aggravation of symptoms existing prior to treatment. I understand that I may refuse this
treatment.
I understand that there may be other treatment alternatives, including treatment offered by a
licensed physician.
I have carefully read and understand all of the above information and am fully aware of what I
am signing. I understand that I may ask my practitioner for a more detailed explanation. I give
my permission and consent to treatment.
Signature: ______________________________
Printed Name:_______________________Date:__________
(In case of minor, parent or guardian must sign)
243 SW 152nd St. burien, WA 98166
206.246.2233 burienhealth.com