New Patient Acupuncture Form

Elyse Saltalamachia, D.C., DABCI

2910 Maguire Rd. Suite 1009

Ocoee FL 34761

P: (407) 877-8707 *** F: (407) 877-7464

Confidential Patient Information

Emergency Contact

Chief Complaint

Secondary Complaint

Health History

Medical History

Health Habits

Temperature
How warm/cold do you feel (not in degrees) relative to other people? (do you wear more or less layers, etc.)

Moisture 

Your overall body moisture (hair, skin, mouth, bowels, etc.)

Digestion 

Energy

Sleep

Emotions

Eyes , Ears , Nose, Throat

Hormonal Changes

Hormonal Balance

Urinary

Other

CONSENT TO ACUPUNCTURE TREATMENT

The undersigned, an adult person desiring acupuncture treatments administered by Dr. Elyse Saltalamachia atLakota Wellness located at 2910 Maguire Road Suite 1009 Ocoee, FL 34761, hereby acknowledges the following:

1. That acupuncture treatments involve the insertion of needles at one or several points in the body, andmethods of treatment can vary as follows, depending on the acupuncturist's judgment.

A. Needle or multiple needles with or without twirling

B. Needle or multiple needles attached to low current (electro-stimulation), replacing manual twirling 

C. Local heat, either by heat lamp or moxa

2. That acupuncture is a procedure which was develop thousands of years ago and has been used in Asiancountries and other parts of the world, but at present is not universally taught in medical schools in the UnitedStates. However, advance acupuncture training is taught in four-year graduate schools of Oriental Medicine and isauthorized by the Board of Medical Quality Assurance, the licensing body of the state of Florida.

3. I understand that the administration of acupuncture could directly or indirectly result in minor adverse effectsto my body including, but not restricted to, lightheadedness, minor bleeding, bruising, soreness, pain and generalrelaxation.

4. I further acknowledge that I am not seeking or undergoing acupuncture as result of any inducement orrepresentation or promises made by the acupuncturist or any other person in the office. I wish to proceed freelyand voluntary with such treatment and authorize Dr. Elyse Saltalamachia to proceed with such treatment with thefull and informed consent on my part of all the relevant facts as set forth in this consent form. This consent shallapply to my initial and all subsequent acupuncture treatments

Informed Consent

Every type of health is associated with some risk of potential problem. This includes chiropractic health care and diagnostic testing. Generally, both are very safe. Thousands of people die every year from prescribed drug complication while only as handful of notable complications arise in the millions of people treated with chiropractic health care. We want you to be informed about the potential problems associated with chiropractic health care before consenting to treatment. This is called "INFORMED CONSENT".

Chiropractic adjustments (manipulations) are moving of bones with the physician's hands or an instrument. Frequently, adjustments make a "pop" or "click" sound sensation in the area being adjusted. In the office, we have trained staff personnel to assist the physician with portions of your consultation, examination, physical therapy application, exercise instruction, etc. Staff members are always under the direct supervision of the physician. Occasionally, when the physician is unavailable, another physician will treat patients.

STROKE: A stroke is the most serious problem associated with spinal manipulation. A stroke means that a portion of the brain does not receive oxygen from the bloodstream. The results are usually temporary (but can be permanent) dysfunction of the brain with an extremely rare complication of death. Spinal manipulations have been associated with strokes that arise from vertebral artery only; this is because the vertebral artery is found inside the neck vertebrae. This is called basilar stroke. In many of these cases the spinal manipulation that is related to vertebral artery stroke is called "extension-rotation thrust atlas adjustment". This office does not perform this manipulation. Other types of neck manipulations may also potentially be related to vertebral artery stroke, but no one knows for certain. One study (journal of CCA, Volume37, June1993 and other) estimated that the incident of this type of stroke is one per every 3 million upper neck manipulations. This means that an average chiropractor would have to be in practice for 1430 years before they statistically be associated with a single patient stroke. Less reliable surrey studied of neurologists between 1994 and 2000 estimated an incidence of 1 in500,000 to 1 million. Dr. Saltalamachia routinely screens patients prior to cervical manipulation to minimize any risk any further.'

DISC HERNIATION: Disc herniations that create pressure on the spinal nerve, or the spinal cord are frequently successfully treated by chiropractors and chiropractic manipulations, traction, etc. This includes both the neck and the back. Yet occasionally manipulations, traction, etc. will aggravate the problem and rarely surgery may become necessary for correction. Rarely chiropractic manipulations may also cause a disc problem; if the disc is in a weakened condition these problems occur so rarely that there are few available statistics to quantify their probability. A 2004 study (JMPT2004 (MAR);27(3)) estimated an incidence of disc herniation occurring in less than 1 in 3.7 million manipulations.

SOFT TISSUE INJURY: Soft tissue primarily refers to muscles and ligaments. Muscles move bones, and ligaments limit joint movement. Rarely a spinal manipulation, traction, etc. may tear some muscle or ligament fibers. The results are a temporary increase in pain and necessary treatments for resolution, but they are not long-term effects for the patient. These problems occur so rarely that there are no available statistics to quantify their probability.

RIB FRACTURES: The ribs are found only in thoracic spine or middle back. They extend from your back to your front chest area. Rarely a chiropractic manipulation will crack a rib, and this is referred to as a "fracture". This occurs primarily on patients that have weakened bones from such things as osteoporosis but can occur in perfectly well people. Osteoporosis may be noted on your x-rays if they are indicated. We adjust all patients very carefully, and especially those who have osteoporosis on their x-rays or DEXA scans or are likely to have undiagnosed osteoporosis by history. These problems occur so rarely that there are no available statistics to quantify their probability.

PHYSICAL THERAPY BURNS: Some of the machines we use generate heat. We also use both heat and ice and recommend them for home care on occasion. Everyone skin has sensitivity to these modalities, and rarely, either heat or ice can burn or irritate the skin. The result is a temporary increase in skin pain, and there may even be some blistering of the skin. We also occasionally use electrical modalities which may occasionally shock and/or burn the skin, long term complications are rare. The problems occur so rarely that there are no available statistics to quantify their probability.

SORENESS: It is common for patients to experience a temporary soreness or increase in soreness on the region being treated by manipulation, traction, etc. This is a normal physiological response while your body is undergoing therapeutic changes and is nearly always temporary, It is not dangerous, but let your physician know of your concerns.

HIP PROSTHESIS: Generally, a hip prosthesis is very stable. However, it is possible that the hip can dislocate during some maneuvers. This can typically be easily reduced but could result in surgery to repair. Older prostheses are more vulnerable. This happens very rarely, so no statistics are available to quantify their probability. The techniques used, further minimize the possibility of hip dislocation.

BREAST IMPLANTS: Most breast implants are exceptionally durable, but they can rupture, especially those that are over 10years old. They typically rupture spontaneously, but it is possible that they could rupture during a manipulation. This could require surgical intervention. This happens very rarely, that no statistics are available. The techniques used further minimize the possibility of implant rupture.

OTHR PROBLEMS: There may be other problems or complications that might arise from chiropractic health care or diagnostic testing other than those noted above. These other problems or complications occur so rarely that it is not possible to anticipate and/or explain them all in advance of care. If you have any further questions, always feel free to consult your physician.

Chiropractic medicine is a system of health care delivery: therefore, as with any other health care delivery system, we cannot promise a cure for any symptom, disease, or condition as a result of care in this office. We will always give you our best care, and if results are not acceptable, we will refer you to another physician/provider who we feel will assist your situation.

If you have any questions regarding the above, please ask the physician prior to signing. When you have a full understanding, please sign below, attesting that all questions have been answered to your satisfaction.

Patient Consent to Telehealth Services and Digital Correspondence

Telehealth services involve the use of electronic communications to enable health care providers to deliver healthcare services to patients using interactive video and audio communications. This document outlines the potential benefits and risks associated with telehealth services and confirms your consent to the use of telehealth services in your health care.

I understand the following:

1. The laws that protect the confidentiality of my personal information also apply to telehealth. 

2. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at anytime, without affecting my right to future care or treatment.3. The same standard of care that would apply to an in-person visit also applies to telehealth. 

4. My health care information may be shared with other individuals for scheduling and billing purposes. 

5. There are certain risks associated with telehealth, including delays in treatment occurring due to deficiencies or failures of equipment, interruptions of service or other technical difficulties, or the breach of privacy of personal health information caused by failure of security protocols. 

6. Certain technical failures may necessitate the rescheduling of my appointment or the continuation of my visit by alternative means. 

7. I am responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telehealth visit, and I understand that health plan payment policies for telehealth visits may be different from policies for in-person visits. 

8. This document will become a part of my health record.

I hereby give my informed consent for the use of telehealth services in my health care. I have personally read this form (or had it explained to me) and fully understand and agree to its contents. My questions about telehealth services have been answered to my satisfaction, and the risks, benefits, and alternatives to telehealth services have been shared with me in a language I understand. I am in and will remain in the state of Florida during my telehealth encounter(s).

Acknowledgment of Patient Digital Communication Correspondence

I hereby consent and state my preference to have Dr. Elyse Saltalamachia and staff of Lakota Wellness to communicate with me by email or standard SMS (text) messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, supplementation, appointments, billing and past/present conditions.

I understand that email and standard SMS (text) messaging are not secure confidential methods of communication and may be insecure. I further understand that because of this there is a risk that email and SMS(text) standards regarding my medical care might be intercepted and read by a third party.

Affirmation of Receipt of Patients Notice of Privacy Rights

I hereby acknowledge receipt of this offices Patient Notice of Privacy Rights provided on my behalf and inaccordance with law and have read and understand my rights to privacy and security of personal healthinformation as a patient of this practice.

HIPAA Acknowledgment and Authorization

I hereby authorize my insurance company or any other third-party payer to pay directly to Lakota Wellness for all charges submitted for services incurred by me. I understand that I will be responsible for all charges not paid by my insurance company or third-party payer. I authorize Lakota Wellness to release information concerning my chiropractic/medical condition to my insurance company, employer, attorney, or multiple health care providers who may be involved in the treatment directly or indirectly and hereby release this office of any consequence thereof. Furthermore, any risks regarding chiropractic treatment will be explained to me by request. I assign payment directly to Lakota Wellness which may cover in whole or part of the services that I have received. the authorization shall be valid until I notify Lakota Wellness in writing of a cancellation. A photocopy of the authorization shall be valid as the original copy.

I hereby acknowledge that I have read the HIPAA Privacy Policy and understand my rights contained in the notice. By way of my signature, I provide Lakota Wellness with my authorization and consent to use and disclose my protected chiropractic/medical care information for the purposes of treatment, payment and health care operations as described in the HIPAA Privacy Policy.

Who would you like to access your records?

Office Policy

There will be a $50 fee for same day or short notice cancellations and missed appointments. There is no charge for cancellations that are made at least 24 business hours before the day of the scheduled appointment. These fees are not covered by insurance carriers; I agree to be responsible for payment in full. Payment in full is required before any future appointments can be scheduled. Patients with a chronic history of failed or broken appointments will have to call the day of to see if times are available since our office will no longer be able to reserve a appointment in advance for you. Our business hours are Monday thru Thursday 9:00am – 6:00pm,Friday 9:00am – 2:00pm and Saturday 9:00am – 3:00pm. Our office is closed Sunday.

Insurance

In order to meet the needs of our patients, we have enrolled in various insurance programs. As you can imagine keeping up with all the individual requirements for each of the insurance companies can be practically impossible. Each program may have different requirements or stipulations that dictate which services can be provide and how often they can be provided. These rules can vary even in the same company with various programs being offered. At Lakota Wellness providing the highest quality in chiropractic/medical care to our patients in an atmosphere of genuine caring is our primary concern. It is possible that your insurance provider may NOT cover every service we provide in our office and in these cases, we will have no choice but to bill you for the services provided. It is not our sole responsibility to know every detail of your insurance company, so if we work together, both doing our parts and familiarizing ourselves with your specific policy, we can focus on what we do best – take care of you.

I understand that my insurance company may disallow and not pay fees related to certain procedures and services that I may receive at this office. If these are disallowed, I understand that I am responsible for payment. I understand that I am also responsible for any balance this is not paid by my insurance company after 30 days

Release of Information

I authorize this office to release any information pertinent to my case to any insurance company, adjuster, and attorney involved in this case and hereby release this office of any consequence thereof. I understand that if the Lakota Wellness accepts me as a patient that I am authorizing them to proceed with any treatment that may be necessary. Furthermore, any risks regarding chiropractic/medical treatment will be explained to me upon my request.

Assignment of Benefits

I hereby instruct and direct my insurance company to pay by check make out and mailed directly to this office for medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges or professional services rendered by this office. If in the event my current policy prohibits direct payment to doctor, then I hereby also authorize and direct you to pay directly to:

Lakota Wellness 2910 Maguire Rd. Suite 1009 Ocoee FL 34761

A photocopy of this assignment shall be considered as effective and valid as the original.

Financial Responsibility

I agree to be financially responsible for all charges incurred at this office including my insurance deductibles, copayments and any services or balance NOT covered by my insurance company. I also acknowledge, understand and agree that any purchase of supplements at Lakota Wellness is non-refundable and cannot be returned.

Waiver of X-rays

I understand that should I require X-rays per Dr. Saltalamachia recommendation I shall be referred to a freestanding facility where X-ray can be performed. I understand that X-rays are not performed at Lakota Wellness and agree to treat my present problem (illness) to the best ability by Dr. Saltalamachia without the complete analysis of an X-ray.

Should any untoward effects develop or any further illness or injury develop directly or indirectly as a result of such treatment, I shall assume full responsibility and in consideration of Dr. Saltalamachia treating me at my request without the benefit of a complete X-ray study and analysis, I do hereby release Dr. Saltalamachia from all causes of action, damages and liabilities arising by reason of said treatment, whether now or here after occurring, and whether now known or unknown between the parties hereto.

Records Release Authorization

Should you have records that we may need to request, please fill out this form and sign

Electronic Signature (e-Signature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Lakota Wellness, LLC. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your paperwork shall be legally binding and such transaction shall be considered authorized by you.