New Client Female

All About Herbs

Thermal Imaging New Client Intake Form

Name*

Date*

Date

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email address*

example@example.com

How did you hear about us

Age*

Gender

Primary Care Physician

Referring Physician

Current Concerns:*

Current Symptoms:*

Current Treatment(s):*

Current Prescription Medication(s):*

Have you had a thermogram at All About Herbs before?*

If yes, was there recommendations to follow up with your doctor?

If yes, did you and what was the outcome?

Please list any surgeries you have had with date, (just the year is fine, but need to know the type of surgeries.):*

Dental History, check all that apply:*

Would you describe your general health as good, fair, or have concerns?*

Please list immediate family health history, include family member and disease, (example: father, heart):*

Do you have any medical diagnoses?*

Do you have any skin lesions or physical abnormalities in the area we will be scanning?*

Do you have any abnormal Ob/Gyn History?*

Is there anything else you would feel is important for us to note?*

The Thermal Imaging report is designed to support, NOT REPLACE, the relationship that exists between you and your Physician. It is a procedure that can alert your doctor to changes that may indicate early disease. It is not intended to replace the Medical Advice of your doctor or licensed medical provider. It is not intended to treat, or cure any ailment you may or may not have.

The information contained within the report is to be used for informational and educational purposes only. Please consult your healthcare provider for advice about a specific medical

Furthermore, you are being assisted by a Certified Clinical Thermographer who IS NOT A LICENSED PHYSICIAN.

Any questions discussed in context to the generated report IS NOT A DIAGNOSIS.
Any health related information shared between persons IS NOT MEDICAL ADVICE AND SHOULD NOT BE TREATED AS SUCH.

CONSULT YOUR PHYSICIAN WITH MEDICAL INQUIRIES OR SPECIFIC DIAGNOSIS RELATED QUESTIONS.

Printed name*

Date*

Date

Signature*

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.

All About Herbs is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

We only submit your health information to EMI for the sole purpose of interpreting you thermal scans.

We only submit your EMI Report to you at the mailing or email address you have provided.

We do not share your information with anyone else, unless we are required to do so by law.

Marketing and Contact.

As a courtesy we may contact you via telephone, text message or email to remind you of your appointment, or to remind you to make a follow up/annual appointment. We will not include any personal health information in these messages.

We will not use your information for any marketing, unless you request to be on our newsletter email list.

Change of Ownership.

In the event that All About Herbs is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that All About Herbs is not required to agree to the restriction that you requested.
You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information.
You have a right to request that All About Herbs amend your protected health information. Please be advised, however, that All About Herbs is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
You have a right to receive an accounting of disclosures of your protected health information made by All About Herbs.
You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

All About Herbs reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, All About Herbs is required by law to comply with this Notice.

All About Herbs is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Dawn Nelson by calling the office at 907-376-8327. If Dawn Nelson is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints

Complaints about your Privacy rights, or how All About Herbs has handled your health information should be directed to All About Herbs by calling the office at 907-376-8327. If All About Herbs' manager is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, DC 20201

I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide All About Herbs with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice

Patients Name print*

Patients Signature*

Date*

Date

Authorization to Use or Disclose Protected Health Information All About Herbs

Patient Name*

Address*

Date of Birth*

Date

Date of Request

Date

As required by the Privacy Regulations, All About Herbs may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

EMI, Electronic Medical Interpretations

Patient Health Information authorized to be disclosed: Thermal Images and related health history

For the specific purpose of (describe in detail) Interpretation of said images

I understand I have the right to:

1.Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization.

2. Inspect a copy of Patient Health Information being used or disclosed under federal law.

3.Refuse to sign this authorization.

4.Receive a copy of this authorization.

5. Restrict what is disclosed with this authorization.

I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.

Signature or Patient or Patients Authorized Representative*

Date*

Date

Patient Name*

Address*

Date of Birth*

Date

Date of Request

Date

As allowed by the Privacy Regulations, I wish for this office to provide the following "Alternative" means of communicating my Protected Health Information:

If appropriate please contact me at the following address

If appropriate please contact me by telephone at the following number

If appropriate please contact me by fax at the following number

If appropriate please contact me by Email at the following Email address: **Emailed reports are FREE, but printed reports have a FEE.***

example@example.com

I have the following additional requests for confidential communications regarding my Protected Health Information: (Please explain)

I understand that there may be additional costs associated with this request and I agree to reimburse this office for such costs.

Signature*

Date*

Date

Breast Thermography Confidential Questionnaire

Name*

First NameLast Name

Birthdate*

Date

Address*

Address

Street Address Line 2

City

Zip

Email

example@example.com

Phone Number

Doctor

All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting ther- mologist and any other practitioner that you specify.

Please Mark Yes or No As It Applies to You*

	Yes	No
Do you have any close relative who has had breast cancer?
Have you ever been diagnosed with breast cancer?
Have you ever been diagnosed with any other breast disease (fibrocystic)?
Have you had any biopsies or surgeries to your breast?
Have you had any breast cosmetic surgery or implants?
Have you had a mammogram in the past 12 months?
Have you had a mammogram in the past 5 years?
Have you had abnormal results from any breast testing?
Have you ever taken a contraceptive pill for more than a year?
Have you suffered with cancer of the womb?
Have you had pharmaceutical hormone replacement therapy?
Do you have an annual physical examination by a doctor?
Do you perform a monthly breast self exam?

How many mammograms have you had in total*

What was your age when you had your first mammogram

How many births have you had?*

Your age at the birth of your first child*

Did your period start before the age of 12*

Or finish after the age of 50

Do you smoke? Check all that apply*

YesNoNot in the last 12 monthsNot in the last 5 years

Had a vaccination in the last 4 weeks? Indicate which arm:*

LeftRightNo

Have you recently had any of these breast symptoms?

	Right Breast	Left Breast
Pain
Tenderness
Lumps
Changes in breast size
Areas of skin thickening or dimpling
Secretions of the nipple

I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report.

By signing below, I certify that I have read and understand the statements above and consent to the examination.

Signature*

Date*

Date

Symptoms & History

Female Patient Only

Disclaimer

Notice of Privacy Practices

REQUEST FOR ALTERNATIVE COMMUNICATIONS