New Patient Online Forms

Medical History

Your input is HIPAA compliant and encrypted for your peace of mind. Please be thorough and help me get to know you and your condition better. I look forward to working with you. Miki Higuchi L.Ac.
Date*

MonthDayYear
Date
How did you find me?
Full Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Emergency Contact*

First NameLast Name
Relationship to you:
Emergency Contact Phone Number*

Area CodePhone Number
Patient date of birth*

MonthDayYear
Date
What is your Gender?*

MaleFemaleOther
Height (if known)
Weight (if known)
Occupation

Have you ever been hospitalized or had a major operation*

YesNo
List past surgeries, illness, and/or injuries here. If known, indicate month/year and age. (This should include minor car accidents, sports injuries, sprains, strains, falls, impact injuries, anything that required treatment and/or recovery, etc.*
What is your primary concern? If applicable, which side and where on the body is your issue? *
Are you under a physician's care?*

YesNo
Do you have a diagnosis? If yes, what is the diagnosis, and by whom was it made?
How long have you had this condition and how did it happen or start? (accident, slow onset, sudden etc.)*
What tests or imaging have you had and when? Please email me your reports or have them on hand at your visit.*
What treatments have you had? What helps? What doesn't?*
What is your current self care routine for your injury or condition? *
Rate your level of pain. 1-10. 10 being the worst. What is your pain at its highest and what is your pain level at its lowest? At what time of day is pain highest and lowest. *

Have you ever had any serious illness not listed above?*

YesNo
If yes, please describe below
Do you use or do you have history of using tobacco?*
If yes, are you currently using tobacco?*
Frequency?
Do you currently use controlled substances*
Type? (ALL INFORMATION IS PRIVATE)
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How healthy do you feel in general?
Is there anything else you would like to add?
Patient, Parent or Guardian

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform the acupuncture clinic of any changes in medical status.
Signature*

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Financial & Office Policies
This office is in-network with CIGNA PPO. All other insurance clients will receive a superbill upon request.

All fees for medical service are due at time of service. We accept cash, credit cards (incuding health savings cards), and personal checks. All charges are due upon receipt.

Treatment Packages:
Packages are pre-paid discounted office visits to be used for treating any issues, or as needed for preventative care. Packages are for those with no acupuncture coverage or those who do not plan on submitting their claims. All patients have a right to un-used funds should they choose to discontinue care. Please be aware that unfinished package visits will revert to the non-discounted rate and deducted from the final reimbursement. Please give 5-7 business days for refunds to be processed.
Initials*

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Cancellations:
As a courtesy to our office and other patients, we ask that you please notify the office at least 24 hours in advance if you need to cancel or reschedule your appointment. Visits cancelled at short notice will be charged at the larger of 50% of the current office visit fee. Frequent cancellations gives this office the right to refuse continued treatment.
Initial*

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Release of Information:
By signing this form you are also authorizing this office upon request from your insurance carrier the release of any medical or other information necessary to process any claims.
Initial*

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CIGNA PPO

Skip this page if enrolled with another plan
For all other networks, a superbill will be provided if you have acupuncture coverage. Payment will otherwise be due at time of service.

*As such, being in-network is not a guarantee of payment. Please take the time to review your own benefits and to understand your deductible, authorization requirements, and allowed number of treatments for acupuncture. Cigna PPO patients will be required to have a credit card on file.
Membership ID
Group Number
Primary Subscriber

First NameLast Name
Primary Subscriber DOB*

MonthDayYear
Date

Notice of Patient Privacy

Health Insurance Portability and Accountability Act (HIPAA)
In accordance with the Federal Privacy Law (HIPAA), SPASM Acupuncture keeps medical information and records, and will only use them for patient treatment, health care operations, and billing purposes.

Treatment: The acupuncturist will use your medical information to give you the best possible care.

Health Care Operation: SPASM Acupuncture will use this information for the appropriate follow-up care and/or patient notification.

Billing Purposes: SPASM Acupuncture will use your medical information to bill the appropriate third party (if applicable) for your care. This may also include making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Disclosure of Information with Extenuating Circumstances:
- Health information will be given to family members in case of emergency or under other circumstances with proper authorization and documentation.
- Health information may be given to other physicians or institutions under emergency situations.
- Information may be given to proper authorities when neglect or abuse is alleged or suspected.
- Information may be provided to courts or other agencies when a subpoena is given to this office.
I understand and agree to the policy above
Type Patient or Guardian Name*
Today's Date*

MonthDayYear
Date

Acupuncture Informed Consent to Treat

SPASM ACUPUNCTURE
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me by the acupuncturist indicated below and/or licensed acupuncturists who now or in the future treat me while employed by, working or associated with, or serving as back-up for the acupuncturist named below.

I understand that methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant taste or smell. I will immediately notify a member of the clinical staff of any unanticipated or upleasant effects associated with the consumption of herbs.

I have been informed that acupuncture is a generally a safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness, or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Rare risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects may occur. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some of the herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rash, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

While I do not expect the staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgement during the course of treatment which the clinical staff thinks at the time, based upon facts then known, is in my best interest. I understand the results are not guaranteed.

I understand that the clinical and administrative staff may review my patient records and lab reports, but all of my records will be kept confidential and will not be released without my written consent.

By signing below, I show that I have read, or have had read to me, the above consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment.
Signature*

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Medical History

Financial & Office Policies

CIGNA PPO

Notice of Patient Privacy

Acupuncture Informed Consent to Treat