New Patient Form

Traditional Chinese Medicine is based on the principle of balancing an individual's body, mind, emotions, and spirit. The following confidential questionnaire is a detailed and invaluable source of information about you. It provides the practitioner with a complete sense of you as a unique individual as opposed to a collection of symptioms.

24 Hour Notice is required for cancellation to avoid a $25 service fee. Payment is due at time of service.

Patient Information

Emergency Contact Information

Gerneral Information

Present Health Concers

Please list you most important health concerns in order of their significance

Health History

Personal Habits

Work Activity

Exercise

Family Informations

General

Skin and Hair

Head, Eyes, Ears, Nose, and Throat

Cardiovascular

Respiratory

Gastrointestinal

Gentio-urinary

Musculoskeletal

Neuropsychological

Gynecology

Pregnancy History

Comments

Family History

Please select for each condition that applies to one of your family members.

Our Clinic Protects Your Health Information and Privacy

This notice describes our office's policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our facility, whether made by facility personnel, or your personal doctor.

We may use and/or disclose medical information about you:

  • To doctors, nurses, technicians, medical students, or other acupuncturist who are involved at taking care of you at our facility
  • So that the treatment and services you receive at our facility may be billed to, and payment may be collected from you, an insurance company or third party

Types of information that we gather and use:

In administering your health care, we gather and maintain information that may include non-public personal information.

  • About your financial transaction with as (billing transactions)
  • From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.
  • From health care providers, insurance companies, workers comp, and your employer, and other third part administrators (ex. Requests for medical records, claim payment information)

In certain states, you may be able to access and correct personal information we have collected about you (information that can identify you-ex. your name, address, social security number, etc)

We at Ebb and Flow acupuncture respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at 802-9027.

By signing below, I confirm that I consent and understand the HIPPA policy.

For complete information on cosmetic acupuncture, or any of the additional services we offer, call Ebb and Flow Acupuncture in Rochester today at 585-348-9838. You can also write to us via email through our website’s contact page.

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