Confidential Health Intake Form Today’s Date:*
Date Format: MM slash DD slash YYYY
Welcome to Integrative Acupuncture and Oriental Medicine!
First Name:*
Last Name:*
State:*
Preferred Name:
Zip:
Date of Birth:*
Date Format: MM slash DD slash YYYY
Work Phone:
Gender:
Home Phone:
Street Address:*
Cell Phone:
City:
Email:*
Would you like to be contacted via email? We communicate via email with our patients to make referrals to other providers, to send you home care recommendations, and to generally communicate with you about changes, updates and news about the practice. We never share your email address. How would you like to be reminded of upcoming appointments? Emergency Contact:
Primary Care Physician:
Relationship:
Primary Care Phone:
Phone:
Other Physician:
Integrative Acupuncture providers work closely with physicians, initial here if you would like us to contact your providers listed above with information about your acupuncture care:
Referred by (provider, newspaper, friend, web, other):
Social Security Number (*only required for billing Veteran’s Affairs):
Employer and Work Status:
General Information
Please Advise Provider if you are/or a possibility that you are pregnant.
Is this condition related to an accident? Y N Type (auto, work, other)
Date of Accident:
Date Format: MM slash DD slash YYYY
Have you ever been treated by acupuncture or Oriental Medicine before? What is/are the main problem(s) you would like us to help you with:*
How long ago did this problem/s begin?
Is there a known cause/instigating factor for your problem?
Have you been given a diagnosis for this problem? If so what?
What kinds of treatment have you tried?
What seems to help the most?
What seems to aggravate the condition the most?
Please list all medications and supplements you are currently taking.
Please list any allergies you have.
The providers at IAOM are in network with CIGNA, Blue Cross/Blue Shield, United Healthcare, Aetna, Optum, Healthcare, we also accept workers compensation programs and other personal injury plans. We will bill other insurance companies out of network as a courtesy to our patients if the plan includes acupuncture.
Insurance Information
(Do not complete if you do not have acupuncture coverage)
Insurance Co.:
Subscriber Name:
Subscriber DOB:
Relationship To Patient:
Group Number:
ID Number:
Secondary Insurance Company/MEDICARE:
ID Number:
Case Worker (Workers Comp)/Case:
Cell Phone:
Contact Number:
Assignment of Benefits: I certify that I am covered under the above insurance policy and assign benefits
directly to Integrative Acupuncture & Oriental Medicine, LLC. I understand that I am financially responsible for
all charges whether or not they are paid by insurance. I authorize the use of my signature on all insurance
submissions. I give Integrative Acupuncture & Oriental Medicine, LLC permission to exchange information
with the above named insurance company and my other health care providers for purposes of billing and
coordination of care.
Signature:* Date:*
Date Format: MM slash DD slash YYYY
Print Name:
Relationship to Patient (if applicable):
Patient Fee Schedule & Cancellation Policy
Our complete patient fee schedule is available at the front desk. We discount the fee schedule listed service fees by 35% of the billed amount for time of service (non-insured) patients. If you have any questions about our billing, please ask at the front
desk. Please read and sign our Cancellation Policy below: Payment is due at time of service. Co-pays are
due at time of service. We require 24-hours notice of cancellation for all appointments Tuesday - Saturday;
same day cancellations are subject to a $40 fee. No shows are subject to a full time of service fee of $80 (for
both Insurance and Time of Service patients). Monday appointments are considered confirmed by 5pm the
previous Friday. Cancellations received after 5PM Friday will be subject to a $40 late cancellation fee, and no
shows will be charged $80.
Thank you for your understanding.
Please initial here to accept our cancellation policy:*
Disclosure of Information
Professional Qualifications and Experience:
Kerry Boyle is licensed by the State of Vermont to practice acupuncture. She achieved a Masters of Science degree in Acupuncture from Bastyr University in Seattle, WA. She holds a NCCAOM (National Certification
Commission for Acupuncture and Oriental Medicine) certification as a Diplomat in Acupuncture. Kerry has also completed massage therapy training, including licensure with WA state and craniosacaral therapy training, level IV.
Jennifer Etheridge is licensed by the State of Vermont to practice acupuncture. She achieved a Masters of Science degree in Oriental Medicine from Southwest Acupuncture College in Santa Fe, NM. She holds a NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) certification as a Diplomat in Oriental
Medicine.
Jonathan Fleming is licensed by the State of Vermont and the State of Colorado to practice acupuncture. He achieved a Masters of Science degree in Acupuncture from Southwest Acupuncture College in Boulder Colorado. He holds a NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) certification as a
Diplomat in Acupuncture.
Maria Leon is licensed by the State of Vermont and the State of Massachusetts to practice acupuncture. She
achieved a Masters of Acupuncture from the New England School of Acupuncture. She holds a NCCAOM
(National Certification commission for Acupuncture and Oriental Medicine) certification as a Diplomat in Oriental
Medicine.
ZiZi (Jessica) Zolten-Chandler is licensed by the State of Vermont and the State of Hawaii to practice acupuncture. She achieved a Master of Science in Oriental Medicine from the Traditional Chinese Medical College of Hawaii. She holds a NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) certification as a Diplomat in Oriental Medicine.
Please read and sign our Cancellation Policy below:
Payment is due at time of service. Co-pays are due at time of service. We require 24-hours notice of cancellation for all appointments Tuesday - Saturday; same day cancellations are subject to a $40 fee. No shows are subject to a full time of service fee of $80 (for both Insurance and Time of Service patients). Monday appointments are considered confirmed by 5pm the previous Friday. Cancellations received after 5PM Friday will be subject to a $40 late cancellation fee, and no shows will be charged $80.
Thank you for your understanding.
Please initial here to accept our cancellation policy:
Statutory Definition of Unprofessional Conduct:
(а) In addition to any other provision of law, the following conduct by a licensee constitutes
unprofessional conduct. When that conduct is by an applicant or person who later becomes an applicant,
it may constitute grounds for denial of a license or other disciplinary action. Any one of the following
terms, or any combination of items, whether or not the conduct at issue was committed within or outside
the state, shall constitute unprofessional conduct:
(1) Fraudulent or deceptive procurement or use of a license.
(2) Advertising that is intended or has a tendency to deceive.
(3) Failing to comply with provisions of federal or state statutes or rules governing the practice of the profession.
(4) Failing to comply with an order of the board or violating any term or condition of a license restricted by the board.
(5) Practicing the profession when medically or psychologically unfit to do so.
(6) Delegating professional responsibilities to a person whom the licensed professional knows, or has reason to know, is not qualified by training, experience, education or licensing credentials to perform them.
(7) Willfully making or filing false reports or records in the practice of the profession; willfully impeding or
obstructing the proper making or filing of reports or records or willfully failing to file the proper reports or records.
(8) Failing to make available promptly to a person using professional health care services, that person’s
representative, succeeding health care professionals or institutions, upon written request and direction of the
person using professional health care services, copies of that person’s records in the possession or under the
control of the licensed practitioner.
(9) Conviction of a crime related to the practice of the profession or conviction of a felony, whether or not related to the practice of the profession.
(10) In the course of practice, gross failure to use and exercise on a particular occasion or the failure to use and exercise on repeated occasions that degree of care, skill and proficiency which is commonly exercised by the
ordinary skillful, careful and prudent professional engaged in similar practice under the same or similar conditions, whether or not actual injury to a client, patient, or customer has occurred.
(11) Exercising undue influence on or taking improper advantage of a person using professional services, or
promoting the sale of services or goods in a manner which exploits a person for the financial gain of the
practitioner or a third party.
(b) Failure to practice competently by reason of any cause on a single occasion or on multiple occasions may constitute unprofessional conduct. Failure to practice competently includes:
(1) performance of unsafe or unacceptable patient or client care; or
(2) failure to conform to the essential standards of acceptable and prevailing practice.
(c) The burden of proof in a disciplinary action shall be on the state to show by a preponderance of the evidence that the person has engaged in unprofessional conduct.
(d) After hearing, and upon a finding of unprofessional conduct, a board or an administrative law officer may take disciplinary action against a licensee or applicant, including imposing an administrative penalty not to exceed $1,000.00 for each unprofessional conduct violation. Any money received from the imposition of an administrative penalty imposed under this section shall be deposited in the general
fund.
(e) In the case where a standard of unprofessional conduct as set forth in this section conflicts with a standard set forth in a specific board’s statute or rule, the standard that is most protective of the public shall govern.
Filing a Complaint with the Office of Professional Regulation:
File a complaint if you believe a professional has committed misconduct or if you know of someone who is
practicing a profession without a license. Contact the Director at the Office of Professional Regulation by visiting the web site at www.vtprofessionals.org or by calling 802-828-2363 for a complaint form.
Patient’s Disclosure Confirmation:
My signature acknowledges that I have been given the professional qualifications and experience of the
practitioners at Integrative Acupuncture and Oriental Medicine, Kerry Boyle, L.Ac., Jennifer Etheridge L.Ac.,
Jonathan Fleming L.Ac., Maria Leon, L.Ac., and ZiZi (Jessica) Zolten-Chandler, L.Ac., and Darby Rutledge
and a listing of actions that constitutes unprofessional conduct according to Vermont statutes, and the methods for making a consumer inquiry or filing a complaint with the Office of Professional Regulation.
Patient’s Signature* Date*
Date Format: MM slash DD slash YYYY
Consent Form I hereby authorize the licensed acupuncturists; Kerry Boyle, Jennifer Etheridge, Jonathan Fleming, Maria Leon, ZiZi
(Jessica) Zolten-Chandler, and or massage therapist Darby Rutledge to perform the following specific procedures as necessary to
facilitate my diagnosis and treatment:
Acupuncture: insertion of special sterilized needles through the skin into underlying tissues at specific points on the
surface of the body.
Cupping: a technique to relieve symptoms in which cups made of glass or other materials are placed on the skin
with a vacuum created by heat or other device.
Gua Sha: a rubbing on an area of the body with a blunt, round instrument.
Herbs: may be given in the form of pills, powders, tinctures, pastes, plasters, or other forms such as raw herbs to
be cooked. Cooked herbs may be given to take internally or externally as a wash. Herbal formulas may include
shell, mineral, and animal materials.
Moxa: direct and indirect burning on an acupoint using stick, string, or ball moxa to relieve symptoms.
Tuina: an ancient massage used to treat a wide variety of common disharmonies.
Dietary Advice: based on traditional Chinese Medical Theory.
I recognize the potential risks and benefits of these procedures as described below:
Potential risks: discomfort, pain, infection, or blistering at the site of the procedure; temporary discoloration of the
skin; nausea, loose bowel movements, abdominal cramping; and aggravation of symptoms existing prior to the
acupuncture treatment.
Potential benefits: drugless relief of presenting symptoms and improved balance of bodily energies, which may
lead to prevention or elimination of the presenting problem and the strengthening of the constitution.
Notice to Pregnant Women: Labor-stimulating acupuncture points are not used unless the treatment is specifically
for the preparation of labor.
Notice to Pregnant Women: Labor-stimulating acupuncture points are not used unless the treatment is specifically
for the preparation of labor.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to
me by Kerry Boyle, Jennifer Etheridge, Jonathan Fleming, Maria Leon, ZiZi (Jessica) Zolten-Chandler and Darby Rutledge regarding cure or improvement of my condition. I understand that I am free to withdraw my consent
and to discontinue participation in these procedures at any time.
I understand that a record will be kept of the health services provided to me. This record will be kept confidential
and will not be released to others unless so directed by my representative or myself or if it is required or permitted
by applicable law. I understand that I may look at my medical record at any time and can request a copy of it by
paying the appropriate fee. I understand that my medical record will be kept for a minimum of three, but no more
than ten years after the date of my last treatment. I understand that information from my medical record may be
analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any
questions I have will be answered by my practitioner to the best of his/her ability.
I hereby authorize the release of medical information necessary to process my insurance claim. This may include
intake forms, chart notes, reports, correspondences, billing statements and any other information to my attorneys,
health care providers and insurance case managers.
I am responsible for all charges of the services provided. In the event that the insurance company or worker’s
compensation plan denies benefits or makes a partial payment, I am responsible for any balance due (which may
include annual deductibles, co-pays, and/or
co-insurance). This may not apply to insurance companies that I am under contract with.
I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes.
I agree to provide a 24 hour cancellation notice. If I fail to provide 24 hour notice of cancellation, I agree to pay the
canceled/ missed appointment fee. (Please note that insurance companies do not pay this, you do.)
Patient’s Signature* Signature of Personal Representative (if applicable)
Date:*
Date Format: MM slash DD slash YYYY
Description of Personal Representative (if applicable)
Name
This field is for validation purposes and should be left unchanged.
