Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
ACUPUNCTURE NEW PATIENT INFORMATION
Date:
Name:
Age:
Birth Date:
Address:
City
Phone: Home (
)
Work: (
State
)
Cell: (
Zip
)
May we contact you via email:  Yes  No
Email Address:
Social Security No:
Referred By:
Emergency Contact Name:
Emergency Contact Phone: (
)
Relationship to Patient:
Employment Status:  Full Time
 Part time
 Self
 Unemployed
Employer:
 Retired
Occupation:
Marital Status:  Single  Married  Partnered  Widowed  Divorced  Separated
Height:
Weight:
Date of Last Physical:
Condition Evaluation
Reason for your visit (pain, fatigue):
When did you first notice the pain/symptoms:
How often do you experience your symptoms:
 Constant (76 – 100% of the time
 Occasionally (26 – 50% of the time)
 Frequently (51-75% of the time)
 Intermittently (1-25% of them time)
How has your condition interfered with your work:
 Not at all  A little bit  Moderately  Quite a bit  Extremely
How has your condition interfered with social activities (ding out, parties, theater and other social functions):
 Not at all  A little bit  Moderately  Quite a bit  Extremely
How has your condition interfered with recreation (hobbies, exercising, or other leisure activities)
 Not at all  A little bit  Moderately  Quite a bit  Extremely
How has your condition interfered with self-care (showering, getting dressed, eating)
 Not at all  A little bit  Moderately  Quite a bit  Extremely
How do you think the problem began (injury, auto accident, falling):
What activities aggravate your condition (walking, sitting, standing):
What activities make your condition better (ice, heat, resting):
Other doctors seen for your condition:  MD/DO  PT  Massage  Chiropractic  Other
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Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
Activities & Health Review
Habits:
Heavy
Coffee/Tea:

Alcohol:

Soda:

Moderate



Light







Exercise:

Water Intake: 


Tobacco:
Marijuana:
None



Weekly/Daily Amount:
Weekly/Daily Amount:
Weekly/Daily Amount:




Weekly/Daily Amount:
Weekly/Daily Amount:




Weekly/Daily Amount:
Weekly/Daily Amount:
What activities do you do at work or at home?
Sit:
 Most of the day  Half of the day
Standing:
 Most of the day  Half of the day
Computer work:
 Most of the day  Half of the day
On the phone:
 Most of the day  Half of the day




A little of the day
A little of the day
A little of the day
A little of the day
Surgeries
Date
Type of surgery and reason for surgery
List medications taken within the last six months (vitamins, drugs, herbs, etc):
Food allergies / intolerances
Medication allergies
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Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
Health History Review: symptoms your are currently experiencing or have experience in the past 2 years
Constitutional Health
Respiratory
Integumentary
Now Past
Now Past
Now Past








Weight change
Fatigue
Headaches
Migraines










Asthma
Shortness of breath
Bronchitis
Persistent cough
Clearing of throat
Eyes




Hives / Eczema
Rash or itching
Breast pain
Dry skin
Neurological
Now Past
















Blurred/Double vision
Contacts / glasses
Dry/Itch/Burning eyes
Eye disease/injury
Poor/low vision
Spots in front of eyes
Gastrointestinal
Now Past








Change in appetite
Diarrhea
Constipation
Abdominal pain
Now Past



 Lighted Headed /Dizzy
 Tremors
 Head injury
Emotional
Now Past
Genitourinary
Ears/Nose/Mouth/Throat
Now Past














Hearing loss
Ring in the ears
Chronic sinus problems
Nose bleeds
Mouth sores
Bad Taste
Bleeding gums
Now Past












Frequent urgent urination
Painful burning urination
Incontinence or dribbling
Bladder infections
Female – pain with periods
Female – irregular periods










Depression
Anxiety
Panic attacks
Nervousness
Insomnia
Musculoskeletal
Now Past
Cardiovascular
Now Past








Heart trouble/disease
Palpitations
Shortness of breath
Swelling of feet, ankles or
hands












Joint pain
Stiffness or swelling
Weakness
Cramps / spasm
Numbness or tingling
Difficulty walking
Other Health/Health History Information:
01-December-2014 Page | 3
Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
Pain Assessment: Indicate painful or distressed areas.
Rate your AVERAGE pain the past week
Rate your WORST pain the past week
Comments:
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Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
CONSENT FOR ACUPUNCTURE & EAST ASIAN MEDICINE TREATMENT
I hereby authorize Lory Lee, Licensed Acupuncturist and East Asian Medicine Practitioner to perform the following procedure:
 Acupuncture: The insertion of pre-sterilized, single use only disposable needled or lancets through the skin into the
underlying tissues at specific acupuncture points on the surface of the body.
 Electro acupuncture: Using very small amount of electricity to stimulate acupuncture points on the surface of the body.
 Laserpuncture: A laser light beams are applied to specific acupuncture points on the surface of the body.
 Acupressure: The same points on the body are used as in acupuncture, but are stimulated with finger pressure instead of
with the insertion of needles.
 Infrared Therapy: Applying heat generated by an infrared lamp over a specific area of the body.
 Cupping: Applying glass cups on the skin with a vacuum created by heat or suction device.
 Dermal friction therapy: Called gua sha is a method that involves increasing circulation at the surface of the skin by means
of scraping the skin vigorously with a blunt edged object.
 Dietary Advice and Health Education: Based on East Asian medical theory, including the recommendation and sale of herbs,
vitamins, minerals, and dietary and nutritional supplements.
I recognize the potential benefits and risks of these procedures, including but not limited to:
 Potential Benefits: Drugless relief of presenting symptoms and improved balance of body energies that may led to
prevention, improvement or elimination of the presenting condition.
 Potential Risks: Discomfort, pain, bruising, blistering, bleeding, infection at the site of the procedure, temporary
discoloration of the skin, possible aggravation of symptoms existing prior to the acupuncture treatment, dizziness, nausea,
fainting, stuck or broken needle.
Patients with bleeding disorders, pacemakers, who are pregnant, attempting to become pregnant or nursing should
inform the practitioner prior to the treatment.
Qualifications: Lory Lee, L.Ac., EAMP is licensed by the State of Washington, since April 2004 to practice Acupuncture and East
Asian medicine (license number AC2478). She attended Northwest Institute of Acupuncture and Oriental Medicine and where she
received a Master in Acupuncture. She continued her training at Southwest Acupuncture College and received a Master of Science
in Oriental Medicine.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me regarding
cure or improvement of my condition. I do not expect Lory Lee or any other representative thereof to be able to anticipate and
explain all possible risks and complications of the treatment. I have carefully read and understand all the above information and am
fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation of anything regarding
my treatment. I hereby release Lory Lee from any and all liability, which may occur in connection with the above-mentioned
procedures, except for failure to perform the procedures with appropriate medical care. I understand that I am free to withdraw
this consent and to discontinue participation in these procedures at any time. I agree to the release of medical and billing
information necessary for treatment, payment and healthcare operations. I assign benefits payable to Lory Lee. I have received or
decline a copy of the privacy notice.
And to the best of my knowledge, the questions on the Acupuncture New Patient Information and Pain Assessment Form have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to
inform the practitioner of any changes in my medical status. I also authorize the practitioner to perform the necessary services I
need.
Signature of patient or legal authorized individual
Printed name and relationship, if other than patient
Date
Date
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Jade River Acupuncture dba Lory Lee, L.Ac.  33710 9 Avenue South, Suite 1  Federal Way, Washington 98003
th
FINANCIAL AGREEMENT
FULL PAYMENT (DEDUCTIBLES AND CO-PAYS) IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS AND MOST CREDIT CARDS.
It is our goal for patients to clearly understand their financial responsibility before their treatment begins. We want to make your
financial responsibilities as easy as possible. Therefore, we offer the following financial agreements.
1. Patients with insurance: Copay and/or coinsurance estimated portion not covered is due at time of service. If your health
insurance does not cover your First Office Visit there will be additional minimum of $45 charge.
2. Patients without insurance: Payment is due at the time of service.
3. Patients with treatment related to an accident must inform Jade River Acupuncture dba Lory Lee, L.Ac, EAMP at the time of
the first appointment.
4. Balances due that are not paid within 120 days will be sent to collections.
5. A $3.00 service charge per monthly will be attached to unpaid balances past 30 days.
Health Insurance: As a courtesy we bill your insurance carrier. Your health insurance contract is between you and your insurance
carrier and you are fully responsible for any amount that they do not pay. Our office does not guarantee that your insurance will pay
for you Acupuncture treatment. If for any reason your claim is denied, you are responsible for the full amount of your bill. Our office
will not enter into a dispute with your insurance company over any unpaid claim. If your insurance company has not paid your
account in full within 45 days, the balance will be automatically transferred to you for payment. Failure to provide us with adequate
information regarding your insurance may result in a denial from your insurance carrier and you will be responsible for any unpaid
balance.
Authorization Requirements: When insurance companies require pre-authorization, we will apply on your behalf. However, your
insurance company may refuse to authorize the treatment plan. You will be financially responsible for the non-authorized visits.
Third Party Payment: In certain cases, a third party may be responsible for payment of your account. We may hold any outstanding
bills and file a medical lien to secure the payment of this debt. The lien will be filed with the County Auditor’s office and will remain
on file until the account is settled or the claim is closed, at which time payment is due. A charge for processing the lien and
administrative fees will be applied to your account balance.
Missed Appointments: If you fail to show up for your scheduled appointment or do not provide a 24 hours cancellation notice will
be considered a no-show and will be charged $50.00. You will be personally responsible for this charge. This charge will not be
billed to nor paid for by your insurance company. We reserved the right to refuse to schedule future appointments until the fee is
paid.
Package Duration Policy
Packages must be used within 12 month from date of purchase unless otherwise agreed to other terms before the package was
purchased. Package refunds will be prorated at the single treatment fee ($75) for each treatment used.
Gift Certificate Policy
Gift Certificates must be used within 12 months from date of purchase unless otherwise agreed to other terms before the gift
certificate was purchased
Arbitration Agreement: Should any dispute as to malpractice arise, the case will be determined by submission to arbitration as
provided by state and federal law. By signing this you are giving up your constitutional right to have such dispute decided in a court
of law before a jury and are accepting the use of arbitration.
I have read the Financial Policy. I understand and agree to this Financial Policy: I hereby assign payment of Insurance benefits to Jade
River Acupuncture & Wellness Center, Inc.
BY SIGNING BELOW, YOU ARE ACKNOWLEDGING YOUR UNDERSTANDING OF THE OFFICE POLICIES DESCRIBED ABOVE.
Signature of patient or legal authorized individual
Printed name and relationship, if other than patient
Date
Date
01-December-2014 Page | 6