New Patient Appointment 1Book your Appointment2Patient Registration3Medical History4Patient Pain Drawing5Acknowledgements Book Your AppointmentSelect ServiceAcupuncture & Examination Cupping for New Patients Brief Consultation for New Patients Detailed Examination HiddenUntitledDr. Saiyad Ahmad Select your booking time(Required) November 2024 Mon Tue Wed Thu Fri Sat Sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Patient details1. Name(Required) First Last 2. Age(Required)3. Address(Required) Street Address City State / Province / Region ZIP / Postal Code 4. Date of Birth(Required) MM slash DD slash YYYY 5. Gender(Required) Male Female 6. Email(Required) 7. How did you hear about the clinic?8. Do you accept text notifications regarding your visit?(Required) Yes No 9. Phone(Required)10. Contact incase of Emergency:(Required)11. Emergency Contact Name: 12. Emergency Contact Relationship: Symptom Assessment Form1. Primary Reason for Visit(Required)2. Is this an emergency? Yes No 3. Is this an on-job injury/accident? Yes No 4. Is this related to a Motor Vehicle Accident: Yes No 5. How long have you had this condition? 6. Is your condition getting worse? 7. Does the condition bother your: Sleep Work Other Other Reason 8. What may have caused your condition? 9. What makes your condition worse? Insurance Details1. Do You have Health Insurance?(Required) Yes No 2. Policy Holder Name 3. Policy Holder Date of Birth MM slash DD slash YYYY 4. Insurance Carrier Name 5. ID/ Policy # 6. Group # Are you under the care of a physician now? Yes No If yes, what for: Who is your physician(s): Physician Phone # (s): Medical History1. Please check any of the following conditions you currently have or have had in the past. AIDS/HIV Diabetes Measles Seizures Alcoholism Emphysema Multiple Sclerosis Stroke Allergies Epilepsy Mumps Thyroid Disorders Appendicitis Goiter Pacemaker Tuberculosis Arteriosclerosis Gout Pleurisy Typhoid Fever Asthma Heart Disease Pneumonia Ulcers Birth Trauma Hepatitis Polio Venereal Disease Cancer Herpes Rheumatic Fever Chicken Pox High Blood Press. Scarlet Fever Other Other 2. Current Medications Medication Name Strength How Many Per Day? For How Long? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. 3. Known allergies(Required) Write ‘None’ if not applicable.4. Past Surgeries Row ID Date Problem Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. 5. Significant Trauma (ex. auto accidents, falls, injuries)6. Major Medical Conditions in Family History:7. Diet/Life style Poor Appetite Coffee Artificial Sweeteners Alcohol High Appetite Soft Drinks Smoking Tobacco Rec. Drugs High Stress Glasses of Water per day# Typical Diet Includes the Following Foods:Morning Afternoon Evening Snacks Vitamins/ Nutritional Supplements Taken Regularly:(Required) Write ‘None’ if not applicable.Do you Exercise Regularly? Yes No Exercise: Type: How Often: 8. General Symptoms Recent Weight Gain Difficulty Getting to Sleep Sweat Easily Recent Weight Loss Cannot Stay Asleep Fatigue/ Tiredness Difficulty losing weight Fever Dizziness or Vertigo Bruise or Bleed Easily Chills Cold hands or feet 9. Musculoskeletal Neck Pain Muscle Pain Joint Pain Foot Pain Low Back Pain Shoulder Pain Nerve Pain Upper Back Pain Limited Range of Motion Knee Pain Muscle Cramps Body Aches Other(specify): Other 10. Head/ Senses Itchy Eyes TMJ Dry Mouth Sinus Congestion Vision Problems Facial Pain Mouth Sores Runny Nose Glasses Teeth Grinding Excessive Saliva Headaches Sneezing Recurring Sore Throat Ringing in Ears Migraines Dental Problems Hearing Problems Concussion Nosebleeds Abnormal Mouth Taste Excessive Phlegm Color of Phlegm: 11. Digestive Acid Reflux Frequent Gas Vomit Abdominal Pain Heartburn Bloating Hemorrhoids Nausea Diarrhea Itchy Anus Belching Constipation Rectal Pain Bad Breath Mucus in Stools Blood in Stools Crave Sweets Tired After Meals Lightheaded/ Shaky if meals are missed Bowel Movements: Frequency Form loose hard intermediate 12. Respiratory Pneumonia Asthma Bronchitis Shortness of Breath Chest Tightness Cough Wet or Dry? Wet Dry Color of Phlegm 13. Cardiovascular High Blood Pressure Blood Clots Palpitations Difficult Breathing Low Blood Pressure Chest Pain Irregular Heartbeat Other Specify Other 14. Neuropsychological Numbness Depression Emotional Trauma Considered Suicide Seizures Anxiety Seeing a Therapist Tics Stress Easily Poor Memory Other Other 15. Skin & Hair Rash Eczema Excess Hair Loss Dandruff Itching Psoriasis Dry Skin Early Hair Greying Acne Dandruff Fungal Infection Other Specify Other 16. Genitourinary Pain on Urination Incontinence High Libido Impotence Frequent Urination Bedwetting Low Libido Premature Ejaculation Urgent Urination Dandruff Kidney Stones Other Specify Other 17. Gynecological Irregular Periods Clots Painful Periods PMS Vaginal Discharge Breast Pain Discharge Color Length of Cycle: Duration of Flow: Date of Last Period: Date of Last Period: Age at Menopause: # Pregnancies: # Live Births: # Premature Births: 18. Are you experiencing any major regular pain?(Required) Yes No Patient Pain drawing1. Approximately how long have you had this pain? 2. Is this your first episode of this pain? Yes No 3. Is the Pain- Continuous Intermittent 4. When is your pain worst? Morning Daytime Night Random 5. Please indicate the type of pain you are currently experiencing. To refer to the locations of pain you are experiencing, use the corresponding numbers on the below body chart. Numbness Stabbing/ Sharp Ache Burning Pins and Needles 6. Please rate your current pain level by selecting the appropriate number: 1. No Pain 2 3 4 5 6 7 8 9 10. Highest Pain Acknowledgements1. Patient Consent Form(Required) I have read and agree to the patient consent form below..GREEN CRESCENT HERBS AND ACUPUNCTURE CLINIC, INC. 990 S. Sherman St., Richardson TX 75081 (214) 718-7646 Informed Consent to Treatment I consent to acupuncture and/or herbal, nutritional treatments and/or other natural procedures associated with Traditional Chinese Medicine as recommended and administered by Saiyad Ahmad, L. Ac., L.C.H. I have discussed the nature and purpose of my treatment with the acupuncturist. I understand that the methods of treatment may include, but are not limited to, acupuncture, cupping, electrical stimulation, functional medicine, tuina (Chinese therapeutic massage), herbs, nutritional supplements, therapeutic light, and moxibustion. I have been informed that acupuncture is a safe method of treatment, but in rare circumstances, it may have side effects such as bruising and tingling near the needled sites for a few days. In very rare circumstances, acupuncture also carries a potential risk of dizziness, fainting, miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, though the clinic minimizes this risk by only using sterile, disposable needles and maintains a clean and safe environment. Cupping may leave harmless red or purplish spots in the cupped areas for several days. The herbs and nutritional supplements (which are mostly from plant sources, and sometimes animals or minerals) that are recommended are generally considered very safe in Chinese medicine, as long as they are taken in the recommended dosages and only for the appropriate conditions. Some Chinese herbs are toxic in large doses and some may be inappropriate during pregnancy. Some rare side effects of herbs include, but are not limited to, nausea, gas, bloating, vomit, headache, diarrhea, rashes, hives and tingling of the tongue. I understand that herbs can be used in the form of pills, liquid extracts or raw herbs and must only be used as directed. The raw herbs may have an unpleasant taste and/or smell. I will immediately notify the doctor if any unpleasant side effects are noted when taking herbal teas or pills or nutritional supplements. I will notify the acupuncturist if I am or become pregnant. I understand that I should also see my primary care physician to evaluate my condition and understand that I may have to go to a medical doctor or hospital for certain services that Green Crescent Clinic cannot provide, including prescription medicines and emergency treatment. I do not expect the acupuncturist or clinic staff to be able to anticipate all potential risks or complications of treatment, and I wish to rely on their expertise and judgment to conduct what is in my best interest. I understand that the acupuncturist or clinic staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I may seek treatment.2. HIPAA Notice of Privacy Practices(Required) I have read and agree to the HIPAA Notice of Privacy Practices below..HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of privacy practices describes how we may use and disclose your protected health information (PHI) to carry out the treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health and related health care services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require your protected health information to be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. We also may call you by name in the waiting room when your physician is ready to see you. We may use you protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include, as required By Law, information requested for Public Health issues, Communicable diseases, Health Oversight, Abuse or Neglect, the Food and Drug Administration, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Military Activity, National Security, and Workers’ Compensation. Under the Law, we must make disclosures to you when required by the Secretary of the Department of Health & Human Services to investigate or determine compliance with Section 164.500. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object. You may revoke this authorization, at any time in writing, except to the extent that your physician’s practice has already taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights: The following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, then your protected health information will not be restricted. You then have the right to use another healthcare professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically. You have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at the Clinic Main Phone Number. 3. ASSIGNMENT AND PAYMENT AUTHORIZATION(Required) I have read and agree to the ASSIGNMENT AND PAYMENT AUTHORIZATION below..ASSIGNMENT AND PAYMENT AUTHORIZATION Purpose. The purpose of this Assignment is to enable the Office to collect my Charges directly from various Payers, including insurance. Accordingly, I agree to the following and direct all Payers as follows: Definitions. In this Assignment, the following terms shall have the following meaning: “Office” and “Clinic” shall refer to Green Crescent Clinic: “Payer” shall refer to, without limit, any insurance carrier, health benefit plan administrator and fiduciary, health maintenance organization, preferred and independent provider organization, attorney, at-‐fault party, individual, and any other entity, which may elect or be obligated to pay or disburse Proceeds to me, either now or in the future, for any; “Proceeds” shall include, without limit, the proceeds from any settlement, judgment, or verdict, the proceeds from any promise to pay or reimburse, and the proceeds relating to the following benefits, plans, or coverage’s: individual and group health benefits, Medicare, Medicaid, workers’ compensation, disability, liability, uninsured and underinsured motorist, no-‐fault, medical payments benefits personal injury protection, lost wages, lost services, property damage, and malpractice, regardless of whether such Proceeds relate directly to my Charges or not; “Charges” shall include, without limit, the full fees for the Office’s services (including, without limit, treatment, medical equipment, supplies, supplements, narrative reports, photocopies, depositions, and testimony), and Collection Costs incurred by the Office, interest and delinquency penalties to the extent permitted by law, and any other charges incurred by me at the Office; “Collection Costs” shall include, without limit, any pre-‐ and post judgment court costs, filling fees, service of process charges, attorney fees, and any other costs of collection incurred by the Office in any effort or action to collect my Charges either from me or from any Payer. Partial Assignment of the Causes of Action, Assignment of Proceeds, and Contractual Lien. I hereby assign to the Office, insofar as permitted by law, but only to the extent of my Charges, all of my rights, remedies, and benefits relating to any Payer, including without limit my right to receive Proceeds from any Payer now or in the future, and any and all causes of action that I might have against any Payer now or in the future, the right to prosecute such causes of action either in my name or in the Office’s name, and the right to settle or otherwise resolve such causes of action as the Office sees fit. I further grant a contractual lien to the Office with respect to my Charges. I further intend for this Agreement to create a secured interest under the applicable Uniform Commercial Code and herby direct the Office to file the form(s) normally filed with the secretary of state or other governmental agency in order to perfect such lien. Consistent with these provisions, I hereby direct any and all Payers, to pay the Proceeds directly to, immediately to, and exclusively in the name of, the Office to the extent of my Charges. Specific Direction to Any Attorney I Retain, Such as in Accident Cases. In the event that I retain one or more attorneys to assist me in collecting any Proceeds, I hereby direct (and the Office hereby requests) each attorney to provide immediate notice to the Office regarding any Proceeds received by the attorney, to promptly pay the Office in-‐full out of such Proceeds, and to provide a full accounting of such Proceeds to the Office. I agree that the purpose of any Proceeds received by the attorney is to pay my Charges. Other Disclosure Authorization. I hereby direct all Payers to release to the Office any pertinent information regarding any coverage I may have including without limit the amount of the coverage, the amount paid thus far, and the amount of any outstanding claims. I authorize and direct the Office to release any information regarding my treatment or pertinent to my case(s), including without limit a copy of my Charges and a copy of this Assignment, to all Payers in order to facilitate collection of my Charges. Miscellaneous Provisions. Except as provided in this paragraph, this Assignment shall not be modified or revoked without the expressed, written consent of the Office. I hereby revoke, with Office’s consent, the terms of any previously signed documents, but only to the extent those terms conflict with the terms of this Assignment. I agree that each and every provision of this Assignment is reasonably necessary for the protection of the rights and interests of the Office and myself. However, should any provisions of this Assignment be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Assignment shall, nevertheless, remain in full force and effect. This Assignment shall be governed under the laws of the state where the Office is located, and is performable in the country where the Office is located. In any action, based upon this Assignment, I hereby consent to personal jurisdiction and venue of any court in said county and waive all objections based on improper jurisdiction, venue, or forum non-‐convenes as such term is defined by law. I further waive any statue of limitations, which may apply in any action based upon this Assignment. 4. MISSED APPOINTMENT POLICY(Required) I have read and agree to the MISSED APPOINTMENT POLICY below.MISSED APPOINTMENT POLICY PLEASE BE INFORMED THAT IF AN APPOINTMENT IS MISSED WITHOUT 24 HRS. NOTICE OR AN EMERGENCY, THEN A CANCELLATION FEE OF $45.00 WILL BE CHARGED TO YOUR ACCOUNT. WHEN AN APPOINTMENT IS MISSED ANOTHER PATIENT LOSES THE OPPORTUNITY TO BE HELPED AND VALUABLE TIME IS WASTED. WE TAKE YOUR APPOINTMENT AND YOUR HEALTH VERY SERIOUSLY. THANK YOU FOR YOUR UNDERSTANDING Signature below is only acknowledgement that I have received and read all the forms and notices above and am willing to adhere to them:Patient Name(Required) Date(Required) Patient Guardian (if applicable) Signature(Required)CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
