Intake — Quantum Energy Med

Patient Intake Form

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

If session is for a minor (under 18), I consent to treatment as the parent/guardian

Yes

Marital Status

Describe the problem(s) for which you seek help.

Please include dates when each problem occurred (if possible):

Any past medical history?

(previous injuries, accidents, surgeries, etc.) Please include approximate dates.

List any medications (including over the counter) you are presently taking:

Have you taken antibiotics in the past? if so when?

What would a successful treatment outcome look like for you?

What areas of your life give you joy and energy?

Do you exercise? And if so, what kind and how often?

How many hours a night do you sleep? Is your sleep restful? If not, please explain:

Do any family members have similar health issues? If so, please describe:

Please list any areas of pain or discomfort and best describe the level of discomfort on a scale from 1 to 10.

I have received the Notice of Privacy Practice

Read Below

Yes

I agree to the Treatment Consent Form

Read Below

Yes

Notice of Privacy Practice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Commitment to Your Privacy

Cecilia Shaw DAOM is committed to protecting the privacy of your protected health information (PHI). This notice describes our privacy practices, your legal rights, and how we may use and disclose your health information. We are required by law to maintain the privacy of your PHI and to provide you with this notice of our legal duties and privacy practices.

How We May Use and Disclose Your Health Information

1. For Treatment We may use and disclose your PHI to provide, coordinate, or manage your healthcare.

2. For Payment We may use and disclose your PHI to bill and collect payment for services. Since we do not bill insurance, this primarily involves our internal billing records.

3. Appointment Reminders We may contact you via email to remind you of appointments or follow-up care.

5. As Required by Law We will disclose your PHI when required to do so by federal, state, or local law, such as reporting suspected abuse or responding to a court order.

We Will NOT Use or Disclose Your Information Without Your Authorization For:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes (if applicable)
Any other purpose not described in this notice

Your Rights Regarding Your Health Information

Right to Request Restrictions: You may request restrictions on how we use or disclose your PHI. We are not required to agree to your request but will consider it carefully.

Right to Access Your Records: You have the right to inspect and obtain a copy of your health records. We may charge a reasonable fee for copying costs.

Right to Amend: If you believe your health information is incorrect or incomplete, you may request an amendment. We may deny your request in certain circumstances.

Right to an Accounting: You have the right to receive an accounting of certain disclosures of your PHI made by us.

Right to Request Confidential Communications: You may request that we communicate with you about your health matters in a specific way or at a specific location.

Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice at any time, even if you agreed to receive it electronically.

Right to Be Notified of a Breach: You have the right to be notified if your unsecured PHI has been breached.

Our Responsibilities

We are required to maintain the privacy and security of your PHI
We must follow the terms of this notice currently in effect
We will not use or share your information other than as described here unless you give us written permission
We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information

Changes to This Notice

We reserve the right to change this notice. Any changes will apply to all PHI we maintain.

How to Exercise Your Rights or File a Complaint

To exercise any of your rights or if you have questions about this notice, please contact:

Cecilia Shaw ceciliavshaw@aol.com

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

U.S. Department of Health and Human Services Office for Civil Rights Phone: 1-877-696-6775 Website: www.hhs.gov/ocr/privacy/hipaa/complaints

Treatment Consent Form

Services Offered

Cecilia Shaw DAOM offers the following services:

BodyTalk energy medicine sessions: an energy-based approach to health and healing that addresses the whole person
BodyIntuitive Reset Sessions: sessions using muscle testing to identify which resets your body needs.
Acupuncture: Insertion of sterile, disposable needles at specific points on the body.
Adjunctive Therapies: Moxibustion (warming therapy), laser stimulation of acupoints, cupping, and other traditional Chinese medicine modalities.
Herbal Medicine: Recommendation and dispensing of Chinese and Western herbs.
Herbal Injection Therapy
Nutritional Counseling: Dietary guidance and recommendations.
Benefits and Risks

Potential Benefits: Relief from pain, improved function, stress reduction, enhanced wellbeing, improved sleep, digestive support, hormonal balance, and overall health improvement.

Risks of Acupuncture: While acupuncture is generally safe when performed by a licensed practitioner, potential risks include: minor bleeding or bruising at needle sites, temporary soreness, lightheadedness, and in rare cases, infection or injury to underlying structures. All needles used are sterile and disposable.

Risks of Other Modalities: Moxibustion may cause temporary warmth or redness. Herbal medicines may cause digestive upset or allergic reactions in sensitive individuals. Cupping may cause temporary discoloration of the skin.

Acknowledgment and Consent

By clicking the checkbox in the intake form, I acknowledge and consent to the following:

I have been informed of the nature of the services offered by Cecilia Shaw
I understand the potential benefits and risks of treatment
I have had the opportunity to ask questions and all my questions have been answered to my satisfaction
I understand that results may vary and no specific outcomes are guaranteed
I will inform my practitioner of any changes in my health status or medications
I understand that these services are not a substitute for medical care and I should maintain regular contact with my primary care physician
I consent to receive the services described above

Consent for Minors

If the patient is under 18 years of age, a parent or legal guardian must provide consent.

Note: For patients under 16 receiving acupuncture, a parent/guardian must be present during treatment. For patients 16-17, written consent is required and presence is strongly recommended.

Financial Policy

Payment: Payment is due at the time of service. We accept credit cards.

Insurance: We do not accept insurance. You are responsible for full payment of services rendered.

Cancellations: We request 24-hour notice for cancellations. While we do not charge cancellation fees, repeated no-shows or late cancellations may result in difficulty scheduling future appointments.

Products: Herbs and supplements are sold separately and payment is required at time of purchase.