Consent Form - Acupuncture

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INFORMED CONSENT FORM

ACUPUNCTURE CONSENT TO ASSESSMENT & TREATMENT

PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name

Last NameYour Last Name

SUBSTITUTE DECISION MAKER (if any)

First Name (Decison Maker)Decision Maker First Name

Last Name (Decison Maker)Your 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

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.

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

Additional Comments or Restrictions (if any)

0 /

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 have 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. Patients will be responsible for paying 50% OF THE APPOINTMENT FEE if you cancel the same day and THE FULL APPOINTMENT FEE if you do not show up for your appointment.

SIGN & SUBMIT

by Electronic Signature

By typing my name (Patient or Guardian's full name) below, I am electronically signing this consent form.

Patient or Guardian Full Name

Date

Witness Signature

Patient or Guardian Full Name

Date

Copy of this form?

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

Your Email (Optional)a valid email