IVF Intake Form

Please note that all information is strictly confidential.





Medications/Vitamins/Supplements
Please list any medications/vitamins/supplements you are currently taking:

Medications Dosage How Long

NOTICE OF PRIVACY PRACTICES - ACKNOWLEDGEMENT
We keep medical records of the health care services we provide you. You may ask to see and copy your records. You may also ask to correct your records. We will not disclose your records unless you give us written consent or unless the law authorizes or compels us to do so. Your de-identified outcomes could be used for research purposes. You may see or get further information about your records by contacting Acupuncture Northwest & Associates.

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.

Initial:

CONSENT FOR TREATMENT
The "scope of practice" for an acupuncturist in the state of Washington includes but is not limited to the following list of techniques: use of acupuncture needles, use of devices to stimulate acupuncture points, moxibustion, acupressure, cupping, dermal friction, laserpuncture, dietary advice and point injection therapy.

Potential Risks may include but are not limited to the following: pain following treatment in insertion area, minor bruising, infection, needle sickness, broken needle, temporary discoloration of the skin, and aggravation of symptoms existing prior to the treatment.

I request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture and Chinese herbology.

Initial:

TREATMENT and PAYMENT AGREEMENT
I agree to be responsible to Acupuncture Northwest & Associates for charges resulting from services rendered at their established rates. I agree all bills are due in full upon request.

Initial:

Certification: I certify that I have read and understand the authorizations given above and I am the patient, or I am duly authorized by the patient to execute the above and accept its terms.