Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Informed Consent

I , ____________________ voluntarily consent to be treated with acupuncture by licensed acupuncturist Abi Morrison. I have read and understand the following.

 

 

Patient Signature


Date:
 

Witness Signature


Date:
 

Parent / Guardian Signature


Date:

Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Health & Medical History

 

Today's Date:  _______


Name: D.O.B.: Phone: Email:
Address: Cell #: Work: Occupation:
Physician:

Current Health Concerns:

Duration:

Other Treatments or Therapies:

Medications and Supplements:

Other Health Concerns:

Significant Injuries, Surgeries, or Illnesses, including dates:

Family Health History - Illnesses, Age & causes of death of Parents and Grandparents:

What sort of Exercise do you enjoy and how often?

How do you relax?


Circle those that apply to you. Underline to indicate family history.

AIDS

Alcoholism

Allergies

Anorexia

Asthma

Birth Trauma

Bladder Issues

Bulimia

Cancer (Type)

Dental Work

Diabetes

Drug Addiction

Gall Bladder Issues

Heart Disease

Hepatitis A/B/C

Herpes

HIV+

Hyper-Active Thyroid

Hyper-Tension

Hypo-Active Thyroid

Kidney Issues

Lyme disease

Multiple sclerosis

Pacemaker

Parkinson’s

Polio

Rheumatic

Scarlet Fever

Seizures

Shingles

Stroke

Tuberculosis

Ulcers

 

Other (Please describe):


 
 
 


Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Nutrition History

 

Today's Date:  _______

 

 

Describe typical meals, including drinks.

 

Breakfast:

Lunch:

Supper:

Food preferences:

Food intolerances:

 

 

How often do you eat the following?

 

Times per Day/Week.


Meat, Fish:

Coffee, Tea:

Soda, Sweets:

Dairy:

 

 

How many times per day/week of the following?

 

Water:

Alcohol:

Nicotine:

 

 

Optimal Nutrition

Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Appointment Policy

Welcome to Red Bird Acupuncture. We are delighted to have you as a patient and look forward to providing you with the highest quality care. In order to optimize your relationship with us, please take a minute to read our appointment policy.

 

Many of our clients are pleased to find out that we are usually on time. This is because a treatment room has been reserved for you, whereas most medical offices overbook by appointment several patients at the same time. That kind of scheduling provides the practitioner with a steady flow of patients by but does not respect the patient's time.

 

Occasionally, there is a a problem with patients who are not used to staying on schedule themselves. With that in mind, if you are going to be more than 15 minutes late, please call to confirm availability.

 

A 24-hour notice for canceled or rescheduled appointments is necessary in order to avoid a cancellation fee of $75. This allows us time to schedule another patient that would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and respect for our time and yours.

 

Any questions regarding my appointments have been addressed. I have read this statement and I fully understand it.

 

 

 

Print name in full



Print name of representative if represented by another



 

Signature



Signature of representative



 

Date



Date



Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Time of Service Payments

In an effort to minimize costs and to create the best possible atmosphere for healing, we have made the following adjustments to our usual and customary rates. We are able to do this because paying at time of service frees this office from time-consuming paper work and tracking of filed insurance claims.

 

At your initial visit, you will be responsible for the new patient office visit fee that will be included on your bill. At each follow-up visit, you will be responsible for the established patient office visit fee that will be included on your bill. However, there are several procedures that may be used during your visit (initial and/or follow-up). Any of the following procedures used during your treatment will be reduced to $0.00, and you will be responsible for the office visit fee only.

 

97810 -  Acupuncture Initial 15 Minutes $75 per unit 97813 -  Acupuncture w/ Electrical Stimulation Initial 15 Minutes $100 per unit
97811 -  Acupuncture Additional 15 Minutes $75 per unit 97814 -  Acupuncture w/ Electrical Stimulation Additional 15 Minutes 100 per unit
97010 -  Heat Therapy $40 97140 -  Manual Therapy or Tui-Na Massage 15 min $75 per unit
97014 -  Electrical Stimulation (unattended) 15 minutes $45 97530 -  Kinetic Activities $45
97032 -  Electrical Stimulation (attended) $45 97110 -  Therapeutic Exercises $45
99070 -  Needles Laser therapy or moxa therapy 15 min $75    


$110.00 fee for the first office visit.

$75.00 fee for ongoing care.

Any questions regarding acupuncture payments have been addressed. I have read this statement and I fully understand it.

 

 

 

Print name in full



Print name of representative if represented by another



 

Signature



Signature of representative



 

Date



Date



Red Bird Acupuncture
Abi Morrison L.Ac.
17 Masonic Street,
Rockland, Maine 04841.

Office Financial Policy and Authorization to Bill Insurance

There are two billing options available for you. Please select the one you prefer us to use for your visits. If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.

I authorize my insurance benefits to be paid directly to Red Bird Acupuncture. I also authorize the doctor to release any information and medical records required by my insurance company. I understand that I may revoke this consent by written request, at any time. No other records shall be released without my signed consent.




Signature of Responsible Party



Date: