SAAT Form

Patient's Name:

Address:

Apt/Suite:

City:

State:

Zip Code:

Email:

Social Security #:

Date of Birth

Age:

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

Spouse's Name:

Spouse's Employer:

Work Phone:

Emergency Contact:

Emergency Contact #:

Who may we thank for referring you to our office?

Marital Status:

Single Married Divorced Widow(er)

Race:

White Black/African American American/Alaskan Indian Decline to Answer

Ethnicity

Hispanic/Latino Not Hispanic/Latino

I am here today for an evaluation & evaluation & possible treatment.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date

Medications

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Allergies

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Vaccinations

Influenza Shot

Yes No

Date Received:

Pneumonia Shot

Yes No

Date Received:

Consent to Use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health Information

Your Protected Health Information will be used by Back to Health Chiropractic Center , LLC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day healthcare operations of this office.

Please list those whom we may give your information to:

Name:

Phone #:

Name:

Phone #:

Name:

Phone #:

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed . It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office.

I have received a copy of the Notice of Patient Privacy Policy.

Patient Initials

Requesting a Restriction on the Use or Disclosure of Your Information

You may request a restriction on the use or disclosure of your Protected Health Information.

This office may or may not agree to restrict the use or disclosure of your Protected Health Information.

If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards .

Notice of Treatment in Open or Common Areas

Note that some of your treatment may be performed in an "open area". Private areas are available upon request to discuss your health information upon request.

Patient Initials

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

By my signature below I give my permission to use and disclose my health information.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Legally Authorized Individual Signature

Date

Print Patient's Full Name

Time:

Witness Signature

Date

CONSENT FOR COMPLEMENTARY AND ALTERNATIVE EVALUATION AND THERAPY

I (Please input Name below) the undersigned below request and agree to holistic evaluation and treatment though alternative medicine approaches which may Include Homeopathic/Dietary Supplements/Herbal/Acupuncture and complementary and alternative approaches. I understand that there is a lack of sufficient prior to the alternative medicine evaluation. I understand that a fee for Traditional Medical Consultation are separate from the fee for Holistic Evaluation. I also understand that the fees do not include the cost of any alternative medicine treatment, which includes alternative medicine remedies or approaches. I understand that I will be financially responsible for all services rendered and products received and/or ordered at the time of visit.

Please initial

I consent that I knowingly, intelligently and voluntarily accept the risk of the treatment provided with due care. I also understand that it is best to combine these approaches with conventional Medical Treatment. If I choose to abandon Traditional Medical Treatment exclusively in favor of complementary an Alternative Therapy approaches, I consent that I do so against the advice of Dr. Melani and take full responsibility for this decision.

I understand that I would continue to monitor my condition though Convention Medical Treatment as well as Complementary and Alternative Medicine. I will do so by consulting with both Dr. Melani and my family physician. I consent that I have been advised by Dr. Melani not to eliminate or delay my Conventional Medical treatment without consulting with my family doctor.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

CONSENT FOR COMPLEMENTARY AND ALTERNATIVE THERAPY APPROACH PART II

My Physician Dr. Melani Crocker has clearly discussed in detail the nature and purpose of the treatment, the expected benefits, potential side. Effects, and risk of the Complementary and Alternative Medicine. All the risk and benefits of complimentary and Alternative Medicine versus Conventional Medical Care have been discussed.

I consent that I knowingly, intelligently, and voluntarily accept the risk of treatment provided with due care. I also understand that it is best to combine these approaches with Conventional Medical Treatment. If I choose to abandon Traditional Medical Treatment exclusively in favor of Complementary and Alternative Therapy approaches, I consent that I do so against the advice of Dr. Melani and take full responsibility for this decision.

I verify that neither Dr. Melani nor any of his staff have given guarantees or promises with respect to the outcome of the Complementary and Alternative treatment.

I also understand that some Acupuncture treatment devices are considered investigative devices.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Patient instructions for SAAT treatment:

DO NOT wash your ears the day of your treatment .
Avoid all food and drink 20 minutes Before examination (this includes water).
Avoid if possible, 2 hours prior to your exam,taking any supplements,homeopathic formulas, herbs,especially mint, chocolate,coffee and herbal teas. These
substances could interfere with energetic finding and render evaluation less effective.
Continue to take conventional Western medication as prescribed by other physicians. However, if possible, avoid taking such medications 2 hours prior to your evaluation.
Remove all jewelry before treatment.
Do not wear perfume or cologne.

Bringing People 0Back to Health" One Person, One Family at a Time

Small semi-permanent needles have been inserted in the skin of your ear for treatment purposes. This is part of a treatment through the specialized ear micro system of acupuncture.

You are advised to do the following for the best results:

Avoid exposing the treated ear to water as much as possible.
Needles could be left in the ear for three weeks
Normally no pain is felt at the site of the need unless the area is touched, you sleep on that side or you apply equipment on the ear such as telephones.
As soon as you experience any continuous irritation, spontaneous pain or unusual feeling at the site of the needle/needles, or if the area appears red, please remove the involve needle immediately as instructed. It is imperative that you do so immediately as these signs may signal the beginning of an infection or inflammation. Call this office to schedule replacement of the needle.
Needles for allergy treatment only will be replaced once, free of charge, if they fall out accidentally or spontaneously .
If possible, try to minimize eating the food items being treated.
If possible, try to avoid unnecessary exposure to the substance being treated {mold, dust, etc.)
Needles must be removed if they need to undergo an MRI.
Do not clean your ear the day of your appointment. If there is adhesive residue from previous treatments, ensure it is adequately removed no less than 24 hours before your appointment.

I hereby, acknowledge receiving and understanding the above instructions. I understand that no guarantees have been stated or implied by the above-named physician, designated assistants, or staff with respect to the outcome of the above listed procedure{s).

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

DO NOT CLEAN YOUR EAR THE DAY OF YOUR APPOINTMENT!

If there is adhesive residue from previous treatments, ensure it is adequately removed No Less that 24 hours before your appointment.

Instructions & Acknowledgements Following Soliman Auricular Allergy Treament (SAAT)

Date

Patient Name:

My signature at the bottom of this page acknowledges that all Back to Health Chiropractic Center staff has instructed me to adhere to specific guidelines after receiving SAAT ear acupuncture. I understand and agree that they shall be followed precisely. I acknowledge that I am personally responsible for following them:

I will continue to avoid the substances (allergens) to which I have been allergic. I acknowledge that the Back to Health Chiropractic Center has instructed me to NOT intentionally expose myself to allergens for which I have received treatment.
I will do my best to carefully maintain the semi-permanent acupuncture needles for the required 3 to 4 weeks. They will be removed at home by a family member, friend, or myself by lifting and peeling off the covering tape with a pair of tweezers.
I understand that if lifting the tape does not remove the ear acupuncture needles, they are easily pulled out (by the circular handle) with the tweezers.
I acknowledge that no promise or guarantee of results has been suggested by the Back to Health Chiropractic Center. I understand that I may be allergic to many different substances that could trigger similar symptoms.
I agree to only contact the Back to Health Chiropractic Center for advisement. I will NOT seek the opinions or advice from unqualified or inexperienced individuals (including other practitioners) via social media or other sources.
I understand that if I have received SAAT in support of allergy to foods (such as alpha ga/meat), and choose, on my own accord to try eating that food, I will strictly follow the following guidelines:

a. I will test eating a portion of the food no larger than the size of a grain of uncooked rice.
b. I will test eating only pure, plain unseasoned food
c. I will wait at least 24 hours (with no evidence of allergic reaction) before trying it again.
d. I will very gradually increase the size of the tested food (grain of rice, then pea size, then marble sized, etc.).
e. I will NOT test by eating foods with spices, dry rubs, sauces, mixtures, preservatives, additives, natural flavorings, or other ingredients.
f. I will NOT eat restaurant food (especially fast food) as a test
g. I will NOT eat vacuum-sealed products as a test
h. I will be aware of foods and non-food products containing carrageenan (red seaweed extract), as well as gelatin, marshmallows, and other substances derived from mammalian meat.
i. I understand that if I voluntarily test exposure to an allergen, and it does bother me, I will save a sample of it (in a Ziplock bag stored in the freezer) and call the Back to Health Chiropractic Center immediately to discuss.

I understand and agree to the following the above guidelines. I acknowledge that I am personally responsible for my own choices; the staff of the Back to Health Chiropractic Center has instructed me to avoid intentionally testing the effectiveness of SAAT.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date

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