ACUPUNCTURE TRAETMENT

INFORMED CONSENT FORM

ACUPUNCTURE CONSENT TO ASSESSMENT & TREATMENT

PATIENT INFORMATION

First Name *

Last Name *

SUBSTITUTE DECISION MAKER (if any)

First Name

Last Name

I or my substitute decision-maker consent to Physiomobility Health Group to collect, use and disclose my personal health information for the purpose of providing traditional Chinese medicine or acupuncture to me and for the related purposes set out in Physiomobility written Privacy Statement.

The personal health information that may be collected, used or disclosed by the Clinic may include the following, among other things:

● my birth date and contact information
● my health and my family health history
● my health status
● the health care I receive (including identifying my health care provider(s))
● my health number
● the identification of my substitute decision-maker, if any
● insurance or billing information relating to health care

I understand that there may be situations in which practitioners at Physiomobility will have to collect, use or disclose personal health information without my consent, but that they will only do this if permitted by law.

How My Information Will Be Used

I understand that my personal health information may be collected, used or disclosed for the following reasons:

● To provide me with traditional Chinese medicine or acupuncture services
● To obtain payment for services provided
● To assist insurance companies with insurance claims verification
● To seek advice for potential treatment options
● To provide or arrange health care in cases of emergencies
● To fulfill any obligations as mandated by law

RISKS

The risks associated with acupuncture include minor bleeding and bruising, temporary pain and soreness, nausea, fainting, burns, infection, shock, convulsions, pneumothorax, perforation of internal organs, and stuck or bent needles.

Please inform the chiropractor if you:
● Have or develop any major health issues
● Are pregnant or actively trying to be
● Have been fitted for a pacemaker or other electrical implants
● Have a bleeding disorder or take anticoagulants
● Have damaged heart valves or have a high risk of infection
● Suffer from metal allergies
● Have had prosthetic implants
● Are Immune compromised

Patient Access to Information

I understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions.

Acknowledgment

*Please read carefully and check the following:

I allow Physiomobility to collect, use and disclose my personal health information as outlined above.

Access to information

I understand that I can access my personal health information with some limited exceptions. I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting Physiomobility Health Group, but it may directly affect the services I can receive. My personal health information may still be collected, used or disclosed if permitted by law.

Additional Comments or Restrictions

CANCELLATION or NO SHOW POLICY

We, at Physiomobility are here to provide you with the very best care and attention. We understand that unforeseen events and emergencies occur in everyone’s lives. Out of respect for both your practitioners and your fellow patients we ask that you do your very best to arrive on time and to notify us as early as possible in the event that you are unable to attend. Last minute cancellations and no-shows affect our ability to provide an outstanding experience to all of our patients.

In consideration for our therapists’ time, we have adopted the following policy:

If for any reason you need to cancel or re-schedule your appointment with us, we require a minimum of 24 hours notice for change or cancellation of any appointment. This will allow us to fill the available time slot with another patient who needs our services. A full amount of the service fee will be charged for late cancellation/no show if you cancel the same day or if you do not show up for your appointment. Please note that this fee is not billable to insurance policy and remains your responsibility.

SIGNATURES

By signing (Patient or Guardian) below, I am electronically signing this form and consent to acupuncture treatment as proposed to me.

Sign Date (DD-MM-YYYY)

Patient or Guardian's Signature *Please sign inside the box below. Click on eraser icon to clear the box

If you are a guardian and signing on behalf of a patient, please enter your full name below:

Guardian's Name

Witness Signature Please sign inside the box below. Click on eraser icon to clear the box

Witness Name

COPY OF THIS CONSCENT (optional)

If you would like to receive a copy of this signed consent form, please provide an email address below:

Email Address: