Download - INFORMED CONSENT TO TREAT...uriticaria (hives), and feelings of swelling of the whole body. • People with chronic liver and/or kidney dysfunction should not take frequentB12 injections;

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------------------------------------------------------------------------------------------------------------------------------------------------------------------------


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.


VitaminBComplexInjectionConsentAngelaMSoto,O.MD,L.AC

BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------------


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----------------------------------------------------------------------------------------------------------------------------------------------------------------


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


GACInjectionConsentAngelaMSoto,O.MD,L.AC

BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------


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


HomeopathicInjectionTherapyConsent

AngelaMSoto,O.MD,LAc

BlueRootAcupuncture,LLC Confidential----------------------------------------------------------------------------------------------------------------------------------------------------------------------


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------------------------------------------------------------------------------------------------------------------------------------------------------------------


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.

Download - INFORMED CONSENT TO TREAT...uriticaria (hives), and feelings of swelling of the whole body. • People with chronic liver and/or kidney dysfunction should not take frequentB12 injections;

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