informed consent to treat...uriticaria (hives), and feelings of swelling of the whole body. •...
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INFORMEDCONSENTTOTREATAngelaSoto,O.MD,LAc–Practitioner
MarinaSebire&NicoleElmiger–Assistants BlueRootAcupuncture,LLC Confidential-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
Iherebyrequestandconsenttotheperformanceofacupuncturetreatmentsandotherprocedureswithinthescopeofthepracticeofacupunctureonme(oronthepatientnamedbelow,forwhomIamlegallyresponsible)bytheacupuncturistindicatedaboveand/orotherlicensedacupuncturistwhonoworinthefuturetreatmewhileemployedby,workingorassociatedwithorservingasback-upfortheacupuncturistnamedabove,includingthoseworkingattheclinicorofficelistedaboveoranyotherofficeorclinic,whethersignatoriestothisformornot.IalsoherebyrequestandconsenttotheperformanceofGuaShaandStretchingExercisestothemedical/officeassistantsofBlueRootAcupuncture.Iunderstandthatmethodsoftreatmentmayinclude,butarenotlimitedto,acupuncture,moxibustion,cupping,electricalstimulation,Tui-Na(Chinesemassage),Chineseherbalmedicine,nutritionalcounseling,botanicalmedicine,cosmeticacupuncture,cosmetichomeopathicinjections,homeopathy,GuaSha,IonCleanse,acupunctureinjectiontherapy,ozonetherapy,andprolozonetherapy.Iwillimmediatelynotifyamemberoftheclinicalstaffofanyunanticipatedorunpleasanteffectsassociatedwiththeconsumptionoftheherbs,oranynutritional/botanicalsupplement.Ihavebeeninformedthatacupunctureandacupunctureinjectiontherapyaregenerallysafemethodsoftreatment,butthatitmayhavesomesideeffects,includingbruising,numbnessortinglingneartheneedlingsitesthatmaylastafewdays,anddizzinessorfainting.Burnsand/orblistersand/orscarringarepotentialriskofmoxibustion,cupping,andGuaSha,orwhentreatmentinvolvestheuseofheatlamps.Discolorationisacommonsideeffectofcupping,GuaSha,andinjectiontherapy.Unusualrisksofacupunctureincludespontaneousmiscarriage,nervedamageandorganpuncture,includinglungpuncture(pneumothorax).Infectionisanotherpossiblerisk,althoughtheclinicusessteriledisposableneedlesandmaintainsacleanandsafeenvironment,atalltimes.
Iunderstandthatwhilethisdocumentdescribesthemayorrisksoftreatment,othersideeffectsandrisksmayoccur.Theherbsandnutritionalsupplements(whicharefromplant,animalandmineralsources)thathavebeenrecommendedaretraditionallyconsideredsafeinthepracticeofChinesemedicine,althoughsomemaybetoxicinlargedoses.Iunderstandthatsomeherbsmaybeinappropriateduringpregnancy.Somepossiblesideeffectsoftakingherbsarenausea,gas,stomachache,vomiting,headache,diarrhea,rashes,hivesandtinglingofthetongue.IwillnotifyaclinicalstaffmemberwhoiscaringformeifIamorbecomepregnant.WhileIdonotexpecttheclinicalstafftobeabletoanticipateandexplainallpossiblerisksandcomplicationsoftreatment,Iwishtorelyontheclinicalstafftoexercisejudgmentduringthecourseoftreatmentwhichtheclinicalstaffthinksatthetime,baseduponthefactsthenknown,isinmybestinterest.Iunderstandthatresultsarenotguaranteed.Iunderstandtheclinicalandadministrativestaffmayreviewmypatientrecordsandlabrecords,butallmyrecordswillbekeptconfidentialandwillnotbereleasedwithoutmywrittenconsent.
Byvoluntarysigningbelow,IshowthatIhavereadorhadhavereadtome,theaboveconsenttotreatment,havebeentoldabouttherisksandbenefitsofacupunctureandotherprocedures,andhavehadanopportunitytoaskquestions.IindicatethatIamseekingandrequestingtreatmentofmyownfreewillandagreenottoholdBlueRootAcupuncture,AngelaSoto,O.MD,Lac,heremployees/contractors,successorsorassigns,liableforanyinjuryorlossreceivedasaresultoftreatment.Iintendthisconsentformtocovertheentirecourseoftreatmentformypresentconditionandforanyfuturecondition(s)forwhichIseektreatment.
________________________________________________ _________________________PatientSignature Date________________________________________________ _________________________OfficeSignature Date
DisclosureandInformedConsentforCuppingandGuaShaTreatment
BlueRootAcupuncture,LLC Confidential------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
CuppingandGuaShaaretherapeuticdecompressiontechniquesusedbyAcupuncturistsandChineseMedicalPractitionersforthereliefofmuscularpain,tension,andrespiratorydisorderslikecongestion,cough,wheezingamongothersymptoms.Thesetechniquesareusedtodrawoutcongestedfluidsandtoxinstothesurfacetissuelayers,allowingforfreshbloodandlymphcirculation.Theresolutionofstagnationandgranulationinthetissuesoftenbringsanimmediaterelieffrompain.
Cuppingusesnegativepressurecreatedwithinaspecializedglassorrubbercupthatisappliedtotheaffectedbodypart.Thepressurecanbedeeptoproviderelieffromtension,painandinjuries.Gentlerpressureincreaseslymphflow,circulationandrelaxation,andisexcellentforfacialtreatments.GuaShaissimilartocuppinginresults,butaround-edgedtoolisusedinstrokestopressurespecificareasofmusclepainorareasofcongestion.
Thereisapossibilityofdiscolorationthatcanoccurfromthereleaseandclearingofstagnationandtoxinsfromthebody.Thereactionisnotbruising,butthecellulardebris,pathogenicfactorsandtoxinsbeingdrawntothesubcutaneouslayersfordissipationbythecirculatorysystem.Thereisalsoapossibilityofmusclesorenessafteratreatmentwhichgoesawaygraduallyafterwards.
Thediscoloration(raisedpetechia),or“sha”,willdissipateinassoonasafewhoursorupto1weekdependingonhowdarkitis,andinrelationtoafter-careactivities.Itisimportanttodrinkplentyofwatertostayhydrated,andavoidvigorousexercisefor24hoursaftertreatment.Avoidexposuretoextremetemperatures,includingcold,wetand/orwindyweatherconditions,hotshowers,baths,saunas,hottubs,for24hoursaftertreatment.
FireCupping-Onrareoccasionsblistersmayoccur,eitherfromtheheatorfromfluidsbeingdrawntothesurfacebythecupsandonoccasion,howeverunlikely,apatientmayexperienceablisterfromthecupsorsuctioning/heatingimplement.Smallblistersshouldbeleftalonetohealontheirown,whilelargerblistershouldbedrainedanddressedbytheacupuncturephysician.
Iunderstandthatalltreatmentsatthisfacilityaretherapeuticinnature.Iagreetocommunicatetothepractitionerifanyphysicaldiscomfortoranyissuesduringthesession.IfIchoosetoexperiencecuppingtherapyand/orGuaShaduringtreatments,Iunderstandthepotentialside-effectsandtheafter-carerecommendations.IalsoagreethatIhaveread,understandandwillfollowalltheinformationstatedaboveandwillnotholdthepractitionerresponsible.
________________________________________________ _________________________PatientSignature Date________________________________________________ _________________________OfficeSignature Date
VitaminBComplexInjectionConsentAngelaMSoto,O.MD,L.AC
BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
PatientName:___________________________________________________________________________
DOB:__________________________________Date:___________________________________________
Whatareyourmaincomplaints?______________________________________________________
HaveyouhadVitaminBcomplexinjectionsbefore?_________________________________
Where?___________________________________________________________________________________
BenefitsofVitaminBComplex
B1(Thiamine)Thiamineisconsideredan“anti-stress”vitaminandisusedinboostingtheimmunesystem,diabeticpain,heartdisease,alcoholism,aging,atypeofbraindamagecalled“CerebellarSyndrome”,cankersores,visionproblemssuchascataractsandglaucoma,motionsickness,andimprovingathleticperformance.Somepeopleusethiamineformaintainingapositivementalattitude,enhancinglearningabilities,increasingenergy,fightingstress,andpreventingmemoryloss,includingAlzheimer'sdisease.
B2(Riboflavin)Riboflavinisusedforpreventingcervicalcancerandmigraineheadaches.Itisalsousedfortreatingacne,musclecramps,burningfeetsyndrome,carpaltunnelsyndrome,andblooddisorderssuchas“CongenitalMethemoglobinemia”and“RedBloodCellAplasia”.Somepeopleuseriboflavinforeyeconditionsincludingeyefatigue,cataracts,andglaucoma.Otherusesincludeincreasingenergylevels,boostingimmunesystemfunction,maintaininghealthyhair,skin,mucousmembranes,andnails;slowingaging,boostingathleticperformance,andpromotinghealthyreproductivefunction.
B5(PantotheticAcid)Inadditiontoplayingaroleinthebreakdownoffatsandcarbohydratesforenergy,vitaminB5iscriticaltothemanufactureofredbloodcells,aswellassexandstress-relatedhormonesproducedintheadrenalglands,whicharesmallglandsthatsitatopthekidneys.VitaminB5isalsoimportantinmaintainingahealthydigestivetract.Pantothenicacidisalsousedorallyforosteoarthritis,andrheumatoidarthritis.
B3(Niacin)Niacinisusedforhighcholesterol.Itisalsousedalongwithothertreatmentsforcirculationproblems,migraineheadache,dizziness,andtoreducethediarrheaassociatedwithcholera.Somepeopleuseniacinforacne,leprosy,attentiondeficit-hyperactivitydisorder(ADHD),memoryloss,arthritis,preventingpremenstrualheadache,improvingdigestion,protectionagainsttoxinsandpollutants,reducingtheeffectsofaging,loweringbloodpressure,improvingcirculation,promotingrelaxation,improvingorgasm,andpreventingcataracts.
B12(Methylcobalamin)ThisformofvitaminB12passestheblood-brainfunctiondirectly.Itisrecommendedforautism,chemicalsensitivitiesandmentalhealthconcernssuchdepression,stress,anxiety,bipolar,schizophrenia.Itmaygiveyouenergy,weightloss,andhighermetabolism,deepersleep,loweredcholesterollevels,bettermood,balancedimmunesystem,andmentalclarity.
B6(Pyridoxine)Womenusepyridoxineforpremenstrualsyndrome(PMS)andothermenstruationproblems,"morningsickness"(nauseaandvomiting),depressionrelatedtopregnancyorusingbirthcontrolpills,andsymptomsofmenopause.VitaminB6helpsthebodytomakeantibodies.Antibodiesareneededtofightmanydiseases,maintainnormalnervefunction,andmakehemoglobin.Hemoglobincarriesoxygenintheredbloodcellstothetissues,breakdownproteins,andkeepbloodsugar(glucose)innormalranges.
B9(FolicAcid/Folate)VitaminB9(folicacidandfolate)isessentialfornumerousbodilyfunctions.ThehumanbodyneedsfolatetosynthesizeDNA,repairDNA,andmethylateDNAaswellastoactasacofactorincertainbiologicalreactions.Itisespeciallyimportantinaidingrapidcelldivisionandgrowth,suchasininfancyandpregnancy.Childrenandadultsbothrequirefolicacidtoproducehealthyredbloodcellsandpreventanemia.
PossibleSideEffectsandContraindications:• Someredness,bruisingandswellingattheinjectionsitemayoccur.Thisshouldstarttogetbetterwith
forty-eight(48)hours.• Inrarecases,B12cancausediarrhea,peripheralvascularthrombosis,itching,transitoryexanthema,
uriticaria(hives),andfeelingsofswellingofthewholebody.• Peoplewithchronicliverand/orkidneydysfunctionshouldnottakefrequentB12injections;therefore,we
askthatyouprovideuswiththemostrecentcopyoflabworkifyouhaveone,whichreflectsliverandkidneyfunction–ifnotpleasebe100%sureofthatbeforeweproceedwithanytypeofvitamininjection.
• Interactionswithdrugs:AnticholinergicdrugsinteractwithRIBOFLAVIN(VITAMINB2),medicationsusedforloweringcholesterol(Statins)interactwithNIACIN(VITAMINB3),chloramphenicolcanimpedeontheredbloodcellproducingpropertiesofB12.
• OtherdrugsthatdecreaseorreduceabsorptionofB12:antibiotics,cobaltirradiation,colchicine,colestipol,H2-blockers,meltformin,nicotine,birthcontrolpills,potassiumchloride,protonpumpinhibitorssuchasPrevacid,Losec,Aciphex,Pantaloc,andZidovudine.
• Amiodarone(Cordarone)interactswithPYRIDOXINE(VITAMINB6).
InformedConsenttoTreatment:IhavereadtheinformationregardingrisksandbenefitsoftheBcomplexinjectionsandhaveachancetoaskquestionsonthetreatment.Iunderstandthepossiblecomplicationsoftheinjectiontherapyareminorbruisingandbleedingatinjectedsites,dizziness,headaches,andpossiblefaintingfromthesiteofblood.IunderstandclearlythattheremaybeaslightchanceofsensitivitiesandreactiontotheB12solution.IherebyreleaseAngelaSoto,O.MD,LAcfromallliabilitiesregardingmytreatmentwithBcomplexinjections.
________________________________________________ _________________________PatientSignature Date
________________________________________________ _________________________OfficeSignature Date
VitaminC/AscorbicAcidInjectionConsentAngelaMSoto,O.MD,L.AC
BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
PatientName:___________________________________________________________________________DOB:__________________________________Date:___________________________________________
WhatisVitaminC?AscorbicAcid,morecommonlyknownasVitaminC,isoneamongmanyotheressentialvitaminsthebodyneedstobehealthyandworkefficiently.VitaminCisawater-solubleantioxidant,whichhelpsblockcellulardamagecausedbyfreeradicalsthatoccurwhenourbodiestransformfoodintoenergy.Itisananti-histamineandananti-viral.BenefitsofVitaminCInjections:VitaminChelpsmaintaingoodhealthandhasbeenshowntobebeneficialinactingasananti-oxidant.Ithasbeenreportedtohelptreatconditionssuchasthecommoncold,cataracts,lowironstatus,ulcerativecolitis,andheartdisease.VitaminCalsohelpstoregulatebloodsugarandelevateone’smood.Itshowspromiseinfightingcanceralthoughthishasnotbeenmedicallyprovenatthistime.PossibleSideEffectsofVitaminCInjections:AlternativestoVitaminCinjectionsareOralVitamins,Lozenges,andfruitsandjuices.IunderstandIshouldnotgetthistreatmentifIamdiabetic,onasodiumrestricteddiet,ortakingCoumadin,unlessIgetanacceptablereleasefrommyprimarycarephysician.IcannothavethistreatmentifIamcurrentlypregnantornursing.IfIhaveevershownhypersensitivitytoanycomponentofthisinjection,Ishouldnottakeit.VitaminCInjectionssideeffectsincludebutarenotlimitedto:•Mildsoreness•Temporarydizziness•Afeelingofpainandheadaches•WithrareinstancesofbowelintoleranceordiarrheaInformedConsenttoTreatment:IhavereadtheinformationregardingrisksandbenefitsoftheVitaminCinjectionsandhaveachancetoaskquestionsonthetreatment.Iunderstandthepossiblecomplicationsoftheinjectiontherapyareminorbruisingandbleedingatinjectedsites,dizziness,headaches,andpossiblefaintingfromthesiteofblood.IfanyofthesesideeffectsbecomesevereortroublesomeIwillcontactmyphysicianimmediately.IunderstandclearlythattheremaybeaslightchanceofsensitivitiesandreactiontotheVitaminCsolution.IherebyreleaseAngelaSoto,O.MD,LAcfromallliabilitiesregardingmytreatmentwithVitaminCinjections.________________________________________________ _________________________PatientSignature Date
________________________________________________ _________________________OfficeSignature Date
GACInjectionConsentAngelaMSoto,O.MD,L.AC
BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
PatientName:___________________________________________________________________________DOB:__________________________________Date:___________________________________________
BenefitsofGACPerformanceBoosterItreallyispossibletomaxupyourhorse-powertoliftheavierthanbeforeanddefinethoseabsmorethanever.Withglutamineandarginineworkingtogether,youhaveaforcethat’srunningthroughyourbloodstreamtodeliverimmediatesupporttostressedoutmuscletissue.You’retalkingaboutmusclerepairandprotectionatthecellularleveltoenableyoutobuildnewmusclewhileyourbodyisundergoingreparationatthesametime.Plus,withthetriggerofcertainhormones,yourbodyisalsoreleasingnitricoxide(NO)toopenandwidenthosebloodvesselstoensurethatyourmusclesaregettingmorethansufficientbloodandoxygen.Thismeansyoucanworkoutlongerwithmoreintensityandbetterendurancetoreallygetthepumpyouwant.Ontopofthefat-burningandmuscle-buildingbenefits,you’realsogettingotherpositiveeffectsfromtheincreasedbloodandoxidationlevels.Formales,you’regettingtheaddedbenefitofstamina,efficiency,andpossiblyincreasedlevelsoftestosterone.Thatmeansmoremanliness,endurance,andvirilityinanyenvironmentyouthinkcoulduseimprovement.Perhapstheworkplace,thegym,oreventhebedroom.BenefitsofGACInjections:
• increasedenergy• delayedfatigue• highermetabolicrate• properadiposetissue(fat)metabolism• naturalreleaseofgrowthhormones• naturalreleaseofNO• increasedbloodandoxidationlevels• weightloss• gainleanmusclemass• preventsmusclebreakdown• improvesrecoverytime• improvedsexualability• improvedperformance,endurance,andintensitylevels
HowtoUseGACYouwillonlyneedtotakeapproximately1mlonceaweektostart,unlessadvisedbyyourphysicianotherwise.ThisisbecausetheGACcocktailgentlyandnaturallystimulatesthesebiologicalprocessestotakeplacewhileitremainsinthebody’ssystemlongerthanotherinjectableformulas.Roundsaretypicallydoneinafiveweekseries,andthencanbeginagainafterabreakperiodoftwotothreeweeks.Sincethiscocktailteamsl-arginineandl-carnitinetogetherwithglutamineitcanbeextremelybeneficialto
useapproximately30minutespriortoyourworkouttomakethemostoutofyourinjectionbenefits.Itcanbeinjectedintramuscularly.Thisistodelivertheingredientsstraighttothevascularmuscletissuewhereit’sgoingtobeneededthemost.PossibleSideEffectsofGACInjections:Becausethesecompoundsnaturallyoccurinyourbody,therearenormallyfewsideeffectsexperienced.TheGACcocktailformulaisdesignedtoprovidetherightamountofstimulationneededtosupportandencouragethebenefits.ThisenablesinjectableGACtobeusedwithoutcompromisingyourhealthornegativelyinterferingwithanyotherbiologicalprocesses.Sideeffectsareveryrare,butsomeofthesymptomsincludeitchiness,redness,andswellingattheinjectionsite,infection,andtissuedamageorskinchanges.OthersideeffectsrelatedtotheGACcomboarerarelyexperienced,butcanbe:
• nausea• vomiting• diarrhea• abdominalpain• light-headedness,headaches
Symptomssuchascoughing,swellingintheface,difficultybreathing,askinrashandfeverorchillscansignifyanallergicreactionandyoushouldseekmedicalattentionimmediately.Sincetheseaminoacidsshouldnotbeusedwhencertainmedicalconditionsarepresent,andwithvariousmedications,itisimportanttoalwaysconsultwithyourprimaryphysicianbeforeuse.ThiswillruleoutanyunderlyingconditionsthatmaypreventyoufromgettingthefullbenefitsoftheGACcocktail.Tomaximizeonallthecleaneating,weightlifting,andintenseworkouts,giveyourbodytheextraencouragementitneedsbyprovidingitwiththeultimateperformanceboostingsupplementtomakeithappen.WithGAC,you’llbeabletolosethatflab,tightenupthoseabs,andhavethatbodythatyou’vealwayswanted.Withalltheextraenergyatyourdemand,you’llhavemoretimeandstaminatoputittouseinamorepleasurablesettingtoo…anotherreasontowalkawaywithasmileonyourface.InformedConsenttoTreatment:IhavereadtheinformationregardingrisksandbenefitsoftheGACinjectionsandhaveachancetoaskquestionsonthetreatment.Iunderstandthepossiblecomplicationsoftheinjectiontherapyareminorbruisingandbleedingatinjectedsites,dizziness,headaches,andpossiblefaintingfromthesiteofblood.IunderstandclearlythattheremaybeaslightchanceofsensitivitiesandreactiontotheGACsolution.IherebyreleaseAngelaSoto,O.MD,LAcfromallliabilitiesregardingmytreatmentwithGACinjections.________________________________________________ _________________________PatientSignature Date
________________________________________________ _________________________OfficeSignature Date
HomeopathicInjectionTherapyConsent
AngelaMSoto,O.MD,LAc
BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
ThisdocumentisintendedtoserveasconfirmationofinformedconsentforhomeopathicinjectiontherapysuchassuperficialordeepinjectionsasorderedbythephysicianatBlueRootAcupuncture.Ihaveinformedthephysicianofanyknownallergiestodrugsorothersubstances,orofanypastreactionstoanesthetics.Ihaveinformedthedoctorofallcurrentmedicationsandsupplements.IunderstandthatIhavetherighttobeinformedoftheprocedure,anyfeasiblealternativeoptions,andtherisksandbenefits.Exceptinemergencies,proceduresarenotperformeduntilIhavehadanopportunitytoreceivesuchinformationandtogivemyinformedconsent.Iunderstandthattheprocedureinvolvesinsertinganeedleintovariousareasofthebodyandinjectingwhicheverhomeopathicremedy(ies)ingredient(s)AngelaSoto,O.MD,LAchaschosenformytreatment.Risksofhomeopathicinjectiontherapiesincludebutarenotlimitedto:
- Discomfort- Pain- Bruising- Inflammation- Injuryandnumbnessatthesiteofinjection- Fatigue,dizziness,orlight-headfeelingaftertheinjections- Faintingorlossofconsciousnessduringtheprocedure- ExtremelyRarely:Allergicreaction,anaphylaxis,infection,cardiacarrestanddeath
Iamawarethatotherunforeseeablecomplicationscouldoccur.Iamawarethatthepossiblerisksareuncommon,butpossibleofoccurrence.Idonotexpectthephysiciantoanticipateandorexplainallrisksandpossiblecomplications.Irelyonthephysiciantoexercisejudgmentduringthecourseoftreatmentwithregardstoanyprocedure.Iunderstandtherisksandbenefitsoftheprocedureandhavehadtheopportunitytohaveallofmyquestionsanswered.IunderstandthatIhavetherighttoconsenttoorrefuseanyproposedtreatmentatanypriortoitsperformance.MysignatureonthisformaffirmsthatIhavegivenmyconsenttoinjectiontherapywithanydifferentorfurtherprocedureswhich,intheopinionofmyphysician,maybeindicated.MysignaturebelowconfirmsthatIunderstandandagreeto:Theinformationprovidedonthisformandagreetotheforegoing;Theprocedure(s)setforthabovehasbeenadequatelyexplainedtomebymyphysicianand/orassistant(s);IhavereceivedalltheinformationandexplanationIdesireconcerningtheprocedure;Iauthorizeandconsenttotheperformanceofhomeopathicinjectiontherapyandanyprocedure(s)necessaryforthattherapytobecompleteduntomyself.IherebyreleaseAngelaSoto,O.MD,LAcfromallliabilitiesregardingmytreatmentwithBcomplexinjections.________________________________________________ _________________________
PatientSignature Date________________________________________________ _________________________OfficeSignature Date
MissedAppointment/NoShowPolicy
BlueRootAcupuncture,LLC Confidential------------------------------------------------------------------------------------------------------------------------------------------------------------------
2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.Pleasereadcarefully,thenindicateyouragreementatthebottombysigninganddating.
Ourgoalistoprovidequalityhealthcareinatimelymanner.Inordertodosowehavehadtoimplementanappointment/cancellationpolicy.Thepolicyenablesustobetterutilizeavailableappointmentsforourpatientsinneedofhealthcare.
Thedefinitionofamissedappointmentiswhenapatientdoesnotshowupforascheduledappointmentwithoutsufficientnotification,oranynotificationatall.Inotherwords,ifwedonothaveareasonableamountoftimetofillthatemptyslot,itwillbeconsideredamissedappointment.Weaskfornotification24hoursinadvanceifyouknowthatyouwillnotbeabletomakeyourappointment,otherwiseitwillresultinacancellationfee.Weareveryunderstandingaboutcertainsituations.Somenotificationisalwaysbetterthannone,andweareusuallywillingtotakethatintoconsideration.
Whenyourappointmentismade,youwillbegiventhetimeofyourappointmentandthetimeweneedforyoutoarriveatourfacility.Your“appointmenttime”isthetimeyourprovidershouldactuallybeginyourexamination.However,itisimperativethatyouarriveatourfacility10minutespriortoyourappointment.Ifyouare20minuteslatetoyour“appointmenttime”,itwouldthenbedifficulttocompletetheexaminationinthetimeallowedforyourvisit.Therefore,yourappointmentwouldhavetoberescheduled,andyourvisitwouldbeconsideredamissedappointment.Pleasekeepinmindthatthereareotherpatientswhowouldliketobeseenontime,andifyouarelate,itputseveryotherpatientscheduledafterbehind.Wedohavetherighttochargeformissedappointments,andourpolicyisasfollows:
Forestablishedpatients:
• Lastminutecancellations/missedappointments–Willbechargedthefullcostoftheservicebeforeappointmentisrescheduled.
• 3rdmissedappointment-Dischargedfrompractice.• Ifyoucancel2ormoreconsecutiveappointmentsinarow(evenwhennotifyingourstaff
24hoursinadvance),wewillremoveyourfutureappointmentsfromourschedule,ifyouhaveany,toallowotherappointmentstofillthattimeslot.Wheneveryouarecertainyoucanmakeittoyourappointment(s),wewillbehappytoreschedulethem!
Fornewpatients:Thereisadepositfeethatmustbepaidwhenyourinitialappointmentismadeinorderforittobereserved.Youcanpaythedepositeitheroverthephone,mailachecktoourclinic,orpayinpersonatthe
clinicduringnormalofficehours(Notifyusyouarecomingbeforeyoudoifthisisthecase).Onceyourpaymentisapproved,wewillthenholdyourappointment.Thedepositfeeis$70.00,whichishalfoftheinitialappointmentfullcost.Whenyoucomeinforyourappointmentyourprepaiddepositwillbeapplied,leavingyouwiththeremainingbalancedueattheendofyourfirstvisit.Although,ifyoufailtonotifyourstaff24hoursinadvancetocancelyourappointment,thedepositisnon-refundable.Fullpaymentofthevisitisrequiredforsamedaycancellation.
Weprovideconfirmationphonecallsoremailsthedaybeforeyourappointmentasareminder.Thisisacourtesyemailanddoesnotreleaseyoufromyourappointmentobligationifweareunabletoreachyoutoconfirmyourappointment,orifweareunabletocallorsendthatemailforsomereason.
Wewouldsincerelyappreciateforeveryonetounderstandhowmissedappointmentswithoutnotificationareextremelyunfavorabletoourpractice.Allweaskisforasimplephonecalloremailtoletusknowthatyoucannotmakeyourappointmentwithinaminimumof24hoursnotice.
Ifitisafterofficehoursthatyouneedtocancelorrescheduleyourappointment,pleasedonothesitatetoleaveamessageonour24/7answeringmachine,evenifitislate.Amemberofourstaffwillcallyoubackafterweopenthefollowingbusinessday.(Pleasekeepinmind:ifyourappointmentisthefirstappointmentonourscheduleandyoucancelafterofficehoursthenightbefore,wedonotguaranteethatourstaffwillknowofthisuntilwegettotheofficethenextbusinessday.)Also,ifyourappointmentismadewithlessthan24hoursfrommakingtheappointment,tothetimeoftheappointmentbeingmade,thatisyourappointmentconfirmation.
Pleasesignifyunderstandingofthispolicywithyoursignature:
________________________________________________ _________________________
PatientSignature Date________________________________________________ _________________________OfficeSignature Date
ConsenttoEmailand/orTextMessage
forAppointmentRemindersBlueRootAcupuncture,LLC Confidential
------------------------------------------------------------------------------------------------------------------------------------------------------------------------2730DevineStreet•1stFloor•Columbia,SC29205•803-404-7575•www.blueroothealth.com.
Pleasereadcarefully,thenindicateyouragreementbyinitialing,signing,anddatingintheaccordingplaces.
Thankstoadvancesintechnology,thereismorethanonemethodofcommunication.BlueRootAcupuncturestaffhasnoticedthatsomepeopleprefercertainmethodsofcommunicationbetterthanothers.Ourgoalistoaccommodateourpatientsinallaspects,especiallycommunicationmethods.WehavealwayscontactedpatientsthroughBlueRootAcupuncture’sphonenumberand/oremail,butwearenowaddingtheoptionforourpatientstobecontactedthroughtextmessagingfromourstaffs’personalphonenumbers.Ourofficelandlinephoneisunabletosendtextmessages;therefore,ourstaffmustusetheirpersonalphonestoaccomplishthisgoal.Ifyouwouldliketoreceivethiscommunicationfeatureinthefuture,pleasereadtheconsentbelowandsign.Youmaybecontactedviaemailand/ortextmessagingtoconfirmyourfutureappointments,toobtainfeedbackonyourexperiencewithourhealthcareteam,and/ortoprovidegeneralhealthreminders/information.Byadheringtothisfeature,youagreetoreceivethesecommunicationsfromBlueRootAcupuncture’sworkphonenumberandemailaddress,andpossiblyBlueRootAcupuncturestaffs’personalcellphones._________(PatientInitials)IconsenttoreceivingphonecallsandemailsfromBlueRootAcupuncture.
TheemailthatIauthorizetoreceiveemailmessagesforappointmentremindersandgeneralhealthreminders/feedback/informationis__________________________________________________.
_________(PatientInitials)Iconsenttoreceivingtextmessagesfromouremployeephonenumberstomycellphoneandanynumberforwardedortransferredtothatnumber.
ThecellphonenumbersthatIauthorizetoreceivetextmessagesforappointmentreminders,feedback,andgeneralhealthreminders/informationare:803-335-1135
IunderstandthisformistheagreementbetweenmyselfandBlueRootAcupuncture,andIamagreeingtothepossibilityofreceivingemailsand/ortextmessagesfromBlueRootAcupuncturestaff.Myconsenttothisagreementwillapplytoallfutureappointmentreminders,feedback,andhealthinformationunlessIrequestachangeinwriting.
________________________________________________ _________________________PatientSignature Date________________________________________________ _________________________OfficeSignature Date
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