PATIENT INFORMATION

Your Name ____________________________________Birthdate ________________Gender F M Address_____________________________(City) ______________(State) ____ (zip code)___________ Telephone (mobile) ___________________(home) ________________ (work)____________________ E-Mail ______________________________________________________________________________ Single Married Partnership Employed Yes No Student Yes No Employer/School Name _____________________Primary Health Care Provider___________________ Who may I thank for referring you to my office? ____________________________________________ HEALTH INSURANCE INFORMATION Subscriber Name (if different) __________________________Birthdate_________________ F M Relationship to Patient Self Spouse Partner Dependent Other ____________________ Subscriber Address(if different)_________________________________Telephone ________________ Insurance Plan Name_____________________ID # ________________ Group #___________________ Subscriber Employer ________________________________________ Telephone_________________ Is there another health benefit plan? No If yes: Plan Name _____________________________ID # _________________Group #__________________ Is your condition related to: Employment Auto Accident Other Accident Date____________ Claim Number _________________________________Name of Guarantor______________________ Claims Representative___________________________ Telephone Number ______________________ Claims Address _______________________________________________________________________ EMERGENCY CONTACT Name _______________________________Relationship _____________Telephone_______________ PATIENT ACKNOWLEDGMENT The above information is true and correct. I agree to keep Black Mountain Center for Healing current with any changes to the above. I authorize the release of information concerning my treatment to my insurance company, legal advisor and/or referring health care provider. I also authorize payment directly to this office for professional services rendered and am personally responsible for any unpaid balance. SIGNATURE_________________________________________________DATE ____________________ Patient/Representative (include relationship)

Black Mountain Center for Healing 611 Main Street Suite C Edmonds Washington 98020 T: 20425.775.6365

WWW.BLACKMOUNTAINHEALING.COM

CARE AGREEMENT East Asian Medicine East Asian Medicine is a holistic, integrative and complete form of health care, comprised of: acupuncture, herbal therapy, massage, exercise, meditation and nutrition. It is not a substitute for biomedical treatment for those conditions that require referral to allopathic or other appropriate types of care. Treatment may include:

• Acupuncture - insertion of special sterilized needles or lancets directly or indirectly at specific points on or under the surface of the body, including and point injection therapy (water).

• Non-insertive needling - the application of specialized techniques to acupuncture points and meridians that do not puncture the skin including: acupressure, sonopuncture (sound) and cold laser (light).

• Electrical, magnetic or mechanical devices – application of physiologically compatible devices designed to stimulate acupuncture points and meridians.

• Herbal Therapy - raw, pill, granular and/or tincture form (orally); in paste, plaster or wash form topically. Formulas may include shell, mineral and/or animal constituents.

• Nutritional Education - based on East Asian Medicine theory, including herbs, minerals, dietary and nutritional supplements • Education - breathing, relaxation, exercise and Qi Gong techniques. • Cupping - moving or stationery cups, made of glass or other materials, placed on the skin with a vacuum created by heat or

manual suction. • Dermal Friction - rubbing or scraping on an area of the body with a blunt, round instrument. • Moxibustion – direct or indirect burning on or over the skin with forms of artemisia vulgaris (mugwort). • Massage – kneading, pressing, rolling, shaking, and stretching of skin and tissue. • Heat/Cold/Infra-Red - superficial applications.

CranioSacral, Lymph Drainage and Visceral-Neural Manipulation Therapies are gentle non-invasive manual therapies that detect restrictions throughout the body. East Asian Medicine, together with these manual therapies, shares the common goal of locating restrictions and by gentle facilitation disperses and balances the flow of energy within tissues and organs systems. Purpose of Treatment To resolve the reason you are seeking treatment with the goal of promoting health and treating organic and/or functional disorders. To consult and refer treatment for conditions (as defined by Washington State Law) which are outside of the East Asian Medicine and/or Registered Nurse scopes of practice. Potential Risks and Benefits Uncommon risks include but are not limited to:

• temporary minor discomfort during and/or following the treatment • minor bruising, blistering or discoloration at treatment site(s), minor skin burns, infection, broken needle • “needle sickness” (nausea, dizziness, fainting) • gastrointestinal disturbance • temporary aggravation of symptoms that existed prior to treatment

Relief of symptoms, improved balance of body energies which may lead to the restoration of optimal communication among tissues by addressing both the root cause and symptoms of the presenting illness and dis-ease. Patient Rights and Responsibilities I agree to keep Black Mountain Center for Healing informed of my current health history (including medications), treatment recommendations from other health care providers, the possibility of pregnancy, bleeding disorders, pacemakers or other implanted medical devices and hardware. Patient Acknowledgement The above potential risks and benefits of treatment have been explained to me and I have had the opportunity to ask questions. I voluntarily consent to treatment, realizing that no guarantee has been made to me regarding the improvement or cure of my symptoms. I release Asha Novak, RN, EAMP, HP and Black Mountain Center for Healing from any and all liability which may occur in connection with treatment, except for failure to perform it in accordance with current medical standards. I understand that I am free to withdraw my consent to participate at any time. I also agree to abide by policies pertaining to clinic fees, payment obligations and office scheduling agreements. Patient Printed Name _______________________________________________________________________________________ Patient Signature ______________________________________________________________Date _________________________ (Person authorized to consent for patient)

Black Mountain Center for Healing 611 Main Street, Suite C Edmonds, Washington 98020 T:206.498.1545 F:425.775.6365 Registered Nurse 75610 East Asian Medicine Practitioner 2193 Registered Hypnotherapist 60317296

WWW.BLACKMOUNTAINHEALING.COM

NOTICE OF PRIVACY PRACTICES

I, Asha Novak, RN, EAMP, of Black Mountain Center for Healing, am dedicated to protect your privacy rights and the confidential information entrusted by you to me. I am committed to ensure that your health information is never compromised. If these policies and practices are amended, as happens from time to time, you will be informed of any changes that may affect you. PROTECTING YOUR PERSONAL HEALTH CARE INFORMATION I use and disclose the information I collect from you only as allowed by the Health Insurance Portability and Accountability Act and the State of Washington. This includes issues relating to your treatment, payment and healthcare operations. Your personal health information will never be given to anyone, even family members, without your written consent. You, of course, may give written authorization to me to disclose your information to anyone you choose, for any purpose. My office and electronic systems are secure from unauthorized access. My privacy policy and practices apply to all former, current and future patients. You can be confident that your protected health information will never be improperly disclosed or released. COLLECTING PROTECTED HEALTH CARE INFORMATION I will only request personal information needed to provide the health care, implement payment activities and conduct normal healthcare practice operations which comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history and health records. While most of the information will be collected from you, I may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION I am obligated to provide information to law enforcement and governmental officials under certain circumstances. I may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and postcards. PATIENT RIGHTS You have the right to request copies of your healthcare information and to request a list of instances in which I have disclosed your protected information for uses other than stated above. All such requests must be in writing and I may charge for your copies in an amount allowed by law. If you believe your rights have been violated, I urge you to notify me immediately. You can also notify the US Department of Health and Human Services. PATIENT ACKNOWLEDGEMENT I acknowledge that I have received a copy of the Notice of Privacy Practices for Black Mountain Center for Healing. This notice describes the types of uses and disclosures for my protected health care information that might occur during my treatment, payment for services or in the performance of office health care operations. The Notice of Privacy Practices also describes my rights, responsibilities as well as the duties of Black Mountain Center for Healing with respect to my protected health care information. In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the person(s) indicated below: Any member of my immediate family _________________________________________________________ Yes No Spouse or Significant Other (please specify) ____________________________________________________ Yes No Other (please specify) ______________________________________________________________________ Yes No PATIENT SIGNATURE__________________________________________________________ DATE_________________ (or representative, including relationship)

Black Mountain Center for Healing 611 Main Street, Suite C Edmonds, Washington T: 206.498.1545 F: 425.775.6365 WWW.BLACKMOUNTAINHEALING.COM

HEALTH HISTORY

DESCRIPTION OF CURRENT ILLNESS OR CONCERN What health challenges(s) are you experiencing?__________________________________________________________ When did this begin?_______________Do you have an idea what caused it? No If yes________________________ Have you received a diagnosis? No Yes_________________Have you tried any other treatments? No If yes What were they and did they help?_____________________________________________________________________ Does your condition limit your daily activities? No Yes (please describe)____________________________________ What makes it better?_________________________ What makes it worse?____________________________________ How severe is the problem right now? On a scale of 1-10 (10 being the worst)___________________________________ PAST MEDICAL HISTORY Have you had any significant traumas, illnesses, accidents or surgeries? (please list, including the date)______________ __________________________________________________________________________________________________ Do you take any medicines and/or supplements? No If yes (please list)____________________________________ __________________________________________________________________________________________________ Do you have any allergies or sensitivities (environmental, chemical, food, animal)?_______________________________ What is your favorite color?______________________Your favorite season?___________________________________ Do you enjoy foods or flavors with these tastes? Bitter Sweet Spicy Salty Sour Other _____________ Emotionally do you tend to be? Joyful Over thinking Sad Fearful Easily frustrated Other___________ Do you have any? Implanted devices, prostheses or hardware? No If yes where?_________________________ Do you wear contact lenses? No Yes Do you have any loose teeth No If yes, where?_____________________ Are you planning to be or are already pregnant? No Yes (weeks)___________________________ Not applicable Do you have any special concerns or questions about the care you will receive?__________________________________ Is there anything else that I should know that will affect your care? No If yes______________________________ SIGNATURE_____________________________________________________________DATE_______________________ PRINTED NAME_________________________________________________________ RELATIONSHIP_______________

Black Mountain Center for Healing 611 Main Street, Suite C Edmonds 98020 T:206.498.1545 F:425.775.6365 WWW.BLACKMOUNTAINHEALING.COM