Name: Birth Date: / /

Street Address:

Mailing Address:

City: State: Zip: Sex: M F

Home Phone: ( ) Marital Status: Single Married Domestic Partnership

Work Phone: ( ) Occupation: Email:

In case of emergency, contact: Relationship:

Telephone: ( )

How did you hear about us?

Do you have insurance? Yes No HMO? Yes No Insurance Carrier: ________________________________

Policy No. ________________________________ Group No. __________________________________________

Are you being treated elewhere? Yes No Name of Personal Physician : ______________________________

Are you currently using prescription or herbal medicines? Yes No If yes, please list below:

PATIENT INFORMATION INTAKE FORMTo help us provide you with the best possible care, please !ll out this form as accurately as possible. All information

will be kept con!dential in your patient !le.

MEDICAL HISTORY: Please check the boxes below that are now or have been a part of your personal health history.

Arthritis Abortion Allergies (specify) ____________________Anemia Asthma Bleeding Tendency Blood Pressure - High Blood Pressure - Low Bronchitis Cancer

Chronic Fatigue Diabetes Digestive Disorders Emotional Disorders Emphysema Epilepsy Headaches Heart Disease Hepatitis (Specify Type) A ____ B ____C ___Heavy Bleeding

HIV+ Hypogycemia Injuries Insomnia Irregular Pregnancy Menstrual Irregularity Surgery Vaginal Infections Other

Current Past Current Past Current Past

PLEASE TURN OVER.. . . . .COMPLETE & SIGN THE OTHER SIDE

Marcia D. Connelly, L.Ac., Dipl.O.M.Licensed Acupuncturist & Herbalist

6892B Soquel AvenueSanta Cruz, CA 95062831-818-7051

LIFESTYLE: Which of the following is/are a part of your lifestyle?

Tobacco SmokingCo!ee DrinkingAlcohol Drinking

Recreational DrugsBirth Control PillsSoft Drinks / Soda

ExerciseRelaxation/MeditationVitamins/Supplements

PLEASE CIRCLE ANY AREAS OF PAIN OR INJURY:

Sudden Onset vs Gradual Onset Constant vs Intermittent Sharp vs Dull

Spasms/Tremors Sti!ness Numbness Tingling Swelling/Edema Burning Bruising/Tenderness Radiating to

OFFICE POLICY:All fees for medical services are due at the time of visit unless prior arrangements have been made in writing. Acceptable forms of payment are cash, check and credit card.

If you need to cancel or reschedule an appointment, please give a minimum of 24 hours notice. There may be a cancellation fee of $35 for less than 24 hour noti"cation unless otherwise speci"ed by Marcia D. Connelly, L.Ac., Dipl.OM.

Please indicate your understanding and acceptance of these policies by initialling here ________

I value the privacy of your health information. Please ask to review my health information privacy policy.

PATIENT SIGNATURE(Or Patient Representative) X

TOP FOUR MAJOR HEALTH CONCERNS: Please list in order of priority

                                                                                                                                             Marcia  D  Connelly,  LAc,  Dipl.OM                                                                                                                                                                                                      6892B  Soquel  Avenue,  Santa  Cruz,  CA  95062                                                                                                                                                                                                        mcherbgal@gmail.com        831-­‐818-­‐7051   Informed Consent Form I hereby request & consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or the patient named below, for whom I am legally responsible) by the acupuncturist named above and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named above, including those working at the clinic or office listed above, or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxabustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. The clinic uses sterile disposable needles and maintains a clean and safe environment. I have been informed that acupuncture is a generally safe method of treatment but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and less common side effects of dizziness or fainting. Bruising is a common side effect of cupping. I have been verbally informed by my practitioner of the known possible common and rare side effects and risks of acupuncture, moxa, cupping and herbal treatments. I understand that herbs (which are from mineral, plant or animal sources) prescribed may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify my practitioner of any unanticipated or unpleasant effects associated with the consumption of the herbal prescription. The herbs that have been recommended are traditionally considered safe in the practice of Chinese medicine. Some possible side effects of taking herbs are nausea, gas, stomachache, headache, diarrhea, rashes, and hives. I understand that herbal prescriptions and herbal patent medicines are intended only for the person for which they are prescribed and are not to be given to anyone else. I understand that some herbs may be inappropriate during pregnancy, and I will notify the acupuncturist if I am or become pregnant. If I am being treated for labor preparation I understand that this procedure, while traditionally practiced as part of Chinese Medicine, is not considered as a “medical induction of labor” as performed in a hospital setting. Labor preparation treatments are designed to relax the body and in doing so promote the most optimal conditions for labor to arise on its own. I specifically waive my right to any legal claim that may arise through labor preparation treatments. I agree to hold Marcia Connelly, L.Ac.,Dipl.OM harmless for any and all complications that may occur to me or my child as a result of acupuncture for labor preparation. I do not expect the practitioner to be able to anticipate and explain all the possible risks and complications of treatment, and I wish to rely on my practitioner to exercise judgment during the course of treatment which she thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand that my practitioner may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. I understand that if I am paying with insurance, there is no guarantee of benefits and payment by the insurance company, and that if it is decided by my insurance company that acupuncture is not a covered service, or if it is denied without an appeal or an unsuccessful appeal, I agree to pay out of pocket for my treatments. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Name (please print): Date: Patient Signature: Date: (Or Patient Representative; indicate relationship if signing for patient) Office Signature: Date: Form: 2017

Marcia  D  Connelly,  LAc,  Dipl.OM  

                                                   Live  Oak  Acupuncture  &  Healing  Arts  

                                                                                                 Our  Privacy  Policy  

Dear  Valued  Patient,  We  do  our  best  to  protect  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.  In  order  to  maintain  the  level  of  service  that  you  expect  from  our  office,  we  may  need  to  share  limited  personal  medical  and  financial  information  with  your  insurance  company¸  with  Worker’s  Compensation  (and  your  employer  as  well  in  this  instance),  or  with  other  medical  practitioners  that  you  authorize.  

Safeguards  in  place  at  our  office  include:  

• Limited  access  to  facilities  where  information  is  stored.  • Policies  and  procedures  for  handling  information.  • Requirements  for  third  parties  to  contractually  comply  with  privacy  laws.  • All  medical  files  and  records  (including  email,  regular  mail,  telephone,  and  faxes  sent)  are  kept  on  

permanent  file.  

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  transactions  with  us  (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,  workman’s  comp  and  your  employer,  and  other  

third  part  administrators  (e.g.  requests  for  medical  records,  claim  payment  information).  

We  value  our  relationship,  and  respect  your  right  to  privacy.  If  you  have  questions  about  our  privacy  guidelines,  please  call  us  during  regular  business  hours  at    (831)  818-­‐7051.  

 Sincerely,    Marcia  Connelly,  L.Ac.,  Dipl.OM  Live  Oak  Acupuncture  &  Healing  Arts,  6892B  Soquel  Ave,  Santa  Cruz,  CA  95062    I  consent  to  the  use  or  disclosure  of  my  identifiable  health  information  by  Marcia  D.  Connelly,  L.Ac.  (here  after  noted  as  Marcia)  for  the  purposes  of  diagnosis  or  providing  treatment  to,  obtaining  payment  for  my  health  care  bills  or  to  conduct  health  care  operations.  I  understand  that  diagnosis  or  treatment  of  me  by  Marcia  may  be  conditioned  upon  my  consent  as  evidenced  by  my  signature  on  this  document.    I  understand  I  have  the  right  to  request  a  restriction  as  to  how  my  identifiable  health  information  is  used  or  disclosed  to  carry  out  treatment,  payment  or  health  care  operations  of  the  practice.    Marcia  is  not  required  to  agree  to  the  restrictions  that  I  may  request.  However,  if  Marcia  agrees  to  a  restriction  that  I  request,  the  restriction  is  binding  upon  Marcia.    __________________________________________________     _____________________  Signature  of  Patient  or  Authorized  Representative                                                                                                            Date  

 ____________________________________________________________________________  Printed  Name  and  Relationshi