Welcome to Our Community!
Please take a minute to read this introduction to our clinic and to our community. We are delighted that you
are interested in joining us!
What is different about the Community Acupuncture Works clinic?
We treat in a community setting Most US acupuncturists treat patients on tables in individual cubicles. This is not traditional in Asia,
where acupuncture usually occurs in a community setting. In our clinic we use recliners, clustered in
groups, in a quiet, soothing space. Treating patients in a community setting has many benefits: it’s easy
for friends and family members to come in for treatment together; many patients find it comforting; and
a collective energetic field becomes established which actually makes individual treatments more
powerful. Needles will be left in for approximately 60 minutes. Many people fall asleep, and wake feeling
refreshed.
We have a sliding scale Most US acupuncturists also see only one patient per hour and charge $65 to $200 per treatment. They
tend to spend a long time talking with each patient, going over medical records, asking many questions.
We don’t. The only way that we at Community Acupuncture Works can make acupuncture affordable
and still make a living ourselves is to streamline our treatments and see multiple patients in an hour, so
we have returned to the traditional approach; instead of asking you lots of questions, we rely on pulse
diagnosis to decide how to treat you. This is exactly how acupuncture is practiced traditionally in Asia -many patients per hour and very little talking.
Please see the enclosed form that explains our sliding scale. Because we have a sliding scale, we cannot
do insurance billing (that’s the insurance companies’ rule). If you have insurance that covers
acupuncture, we’ll be happy to give you a payment receipt, and you can submit it; that’s OK with the
insurance companies.
Our Commitment to You
We want to make it possible for you to receive acupuncture regularly enough and long enough to improve
and stay well. We want our community to be welcoming to all different kinds of people. We want to give you
the tools to take care of your own health so that you will not need to rely on corporations like Big Insurance
or Big Pharmaceuticals for costly, high-tech interventions. We will provide a safe environment with skilled
practitioners.
What We Need From You
Responsibility
Community Acupuncture Works does not provide primary care medicine! Acupuncture is a wonderful
complement to Western medicine, but it is not a substitute for it. If you think you have a problem that is
not “garden variety” (meaning, you are worried that you might have a serious infection, a malignant
growth, or an injury that won’t heal, or any type of emergency situation), or if you want an expert to go
over the details of your medical history with you, you need to see your primary care physician. You
cannot expect us to and we do not diagnose and treat serious diseases. We can provide complimentary
care for conditions which require a physician’s attention -- for
instance, we often treat patients for the side effects of chemotherapy. But we need you to take
responsibility for your own health.
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
Community Acupuncture Works does not receive grants, state or federal money, or insurance
reimbursement. Community Acupuncture Works exists because patients pay for their treatments – it a
sustainable community business model.
Flexibility
The community setting requires some flexibility from you. For instance, many patients have a favorite
recliner. When we are busy, someone may be sitting in yours. Similarly, we have a few patients who
snore. Other patients who dislike snoring bring earplugs to their treatments. We are grateful for this!
Some of our patients even bring favorite pillows or blankets from home with them, because they prefer
theirs to ours. That’s fine with us. Basically, we need you to participate in making yourself comfortable
in the community room before we arrive to treat you.
If you need to be somewhere at a certain time, please tell the treating acupuncturist. If you want to be
unpinned at a specific time, tell the acupuncturist. We’ll make sure you’re out on time. In general, if you
feel done before we come to remove the needles, open your eyes and give us a meaningful look -- if your
eyes are closed, we think you’re asleep and we won’t wake you up until your time is up.
Community-Mindedness
The soothing atmosphere in our clinic exists because all of our patients create it by relaxing together. We
appreciate everyone’s presence! This kind of collective stillness is a rare and precious thing in our rushed
and busy society. Maintaining this reservoir of calm requires that no one talk very much in the clinic
space. If you would like to speak to a practitioner one-on-one at any length, please let us know. If you
want to have a substantial conversation, we will probably need to schedule that separately and might
need to do it by phone.
If you have questions about acupuncture and how it works -- please read the Little Red Book for
Patients. You can buy a copy for $10 to take home with you, or read our clinic copy. Unfortunately, we
can’t explain what every point does, or how acupuncture works, while we are treating you -- these are
very large topics! This is why our resource material exists. If you have questions, we’ll happily give you
plenty to read!
Part of our success is that our patients learn the “routine” and take on a lot of responsibility for the
appointments. Re-scheduling and making payment happens BEFORE each treatment, so you can relax
and enjoy your treatment. Please take all personal belongings, (bags, shoes, etc.) with you to your chair.
Please remove your shoes only after you have sat down on your chair. And of course, please turn off your
cell phone.
Commitment
Acupuncture is a PROCESS. It is very rare for any acupuncturist to be able to resolve a problem with one
treatment. In China, a typical treatment protocol for a chronic condition could be acupuncture every
other day for three months! Most of our patients don’t need that much acupuncture, but virtually every
patient requires a course of treatment, rather than a single treatment, in order to get what they want
from acupuncture.
One big reason that we are able to keep our prices so low is because of the extraordinary amount of
marketing our patients do on our behalf -- we don’t have to advertise. We cannot express how grateful
we are for this. Our patients become such effective marketers because they have first-hand experience of
how well acupuncture works. All of our satisfied patients have basically made a commitment to a course
of treatment.
On your first visit, your acupuncturist will suggest a course of treatment, which can be anything from
“we’d like to see you once a week for six weeks” to “we’d really like to see you every day for the next four
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
days”. This suggestion is based on our experience with treating different kinds of conditions. If you don’t
come in often enough or long enough, acupuncture probably won’t work for you. The purpose of our
sliding scale is to help you make that commitment. If you have questions about how long it will take to
see results, please ask us, or if you think you need to adjust your treatment plan, please let us know. We
need you to commit to the process of treatment in order to get good results.
And, last, but not least….enjoy the space. We do, and hope that Community Acupuncture Works can be an
important part of your community.
Thank you,
Community Acupuncture Works
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
A little help running the clinic.
Please pay and reschedule before you sit down to receive your acupuncture treatment.
Payment:
Please pay for your treatment before you sit down to receive your acupuncture treatment. In the slot on the
black ballot box find the envelope with your patient number printed on it, put your payment in this envelope
and drop it in the black ballot box attached to the small table. If this is your first visit we will give you your
envelope with your patient number. If this is your first visit there is a one time paperwork fee of $10 in
addition to whatever amount along the sliding scale you decide works for you. Thank you.
$20-$40 sliding scale. You decide what works for you.
If you need a receipt, fill out a receipt from the receipt pad provided, you take one copy and put the other
copy in your envelope with your payment. Please take all personal belongings with you to your chair. Coats
can be hung up on the coat hangers near the front desk. We cannot be responsible for items left in the
waiting area. And of course, please turn off your cell phone or pager.
If you would like to directly support our mission of bringing social justice to healthcare, please contact one
of us regarding volunteer opportunities in our clinic. If we work together, we can heal the world.
Scheduling:
Please find the day that you would like to come in, appointment times will be highlighted, write your patient
number in the desired time slot. Business cards are available if you need to make a note for yourself to
remember your appointment time. It is your responsibility to remember your appointment times. All
appointments that are rescheduled, cancelled or missed with less than 24 hour advance notice will be
charged a $20 fee. Thank you for your understanding.
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
COMMUNITY ACUPUNCTURE WORKS provides high quality acupuncture treatment at affordable
rates in a supportive community setting. We practice a style of acupuncture which mostly uses “distal”
points in the hands, feet and head to treat problems anywhere in the body – meaning we will probably treat
pain in your back by placing tiny needles in your hands. Research in the United States (as well as thousands
of years of tradition in Asia) has shown that acupuncture is most effective when it is done frequently and
regularly – once a week is usually the minimum required to make progress on any kind of health problem.
Community Fee Structure
There is a one-time $10 paperwork fee with the first appointment.
Acupuncture appointments are on a sliding scale of $20 - $40 per treatment.
You decide what you can afford.
The purpose of our sliding scale is to separate the issues of money and treatment; we want you to
come in often enough to really get better and stay better! We understand that everyone’s situation is
different, and our primary goal is to make acupuncture available to you as often as you need it.
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
FINANCIAL POLICY
COMMUNITY ACUPUNCTURE WORKS MAKES EVERY ATTEMPT TO MAKE ALTERNATIVE HEALTH CARE, AS
ACUPUNCTURE AND CHINESE MEDICINE, AVAILABLE TO AS MANY PEOPLE AS POSSIBLE, AT THE MOST
AFFORDABLE RATES.
IN RESPECT FOR OUR INTENTION TO OFFER HIGH QUALITY HEALTH CARE AT AFFORDABLE PRICES, WE
ASK FOR 24 HOURS NOTICE IN ADVANCE OF AN APPOINTMENT IF IT IS NECESSARY TO CANCEL OR
RESCHEDULE AN APPOINTMENT.
ALL APPOINTMENTS THAT ARE RESCEDULED OR CANCELLED WITH LESS THAN 24 HOUR ADVANCE
NOTICE, AND APPOINTMENTS MISSED WITHOUT NOTICE, WILL BE CHARGED THE REGULAR FEE FOR THAT
APPOINTMENT. IF APPOINTMENTS HAVE BEEN PURCHASED IN A PACKAGE, THE MISSED, CANCELLED OR
RESCHEDULED APPOINTMENT WILL BE DEDUCTED FROM THE NUMBER OF REMAINING APPOINTMENTS IN
THAT PACKAGE.
THANK YOU FOR YOUR UNDERSTANDING,
COMMUNITY ACUPUNCTURE WORKS
SIGNATURE _________________________________
DATE ___/___/_____
PRINTED NAME ______________________________
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
INFORMED CONSENT TO TREATMENT
I consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine by
Community Acupuncture Works. I understand that methods of treatment may include, but are not limited to,
acupuncture, moxibustion, cupping, electrical stimulation, massage, Chinese herbal remedies, and nutritional
counseling.
ACUPUNCTURE
I have been informed that acupuncture is a safe method of treatment, but that it may have side effects including
bruising, dizziness or fainting, and numbness or tingling near the needling sites that may last a few days. Unusual
risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture
(pneumothorax). Infection is another possible risk, although this clinic uses sterile disposable single use needles, and
maintains a clean and safe environment.
MOXIBUSTION
Moxibustion involves burning an herb on or near an acupuncture point in order to improve physiological function or
treat pain. Burns and/or scarring are a potential risk of moxibustion.
HERBAL REMEDIES AND NUTRITIONAL SUPPLEMENTS
The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that may be recommended
are traditionally considered safe in the practice of Chinese Medicine. I understand that the herbs need to be prepared
and consumed according to the instructions provided orally and in writing. Some possible side effects of taking herbs
are nausea, gas, stomachache, headache, change in bowel movement or dizziness. Should I experience any
unanticipated effect I will immediately notify Community Acupuncture Works. Also, I will keep Community Acupuncture
Works informed of my current medications.
I understand that some herbs and acupuncture treatments are contraindicated during pregnancy. I will notify
Community Acupuncture Works if I am or intend to become pregnant.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I
also understand that results are not guaranteed. I do not expect Community Acupuncture Works to be able to
anticipate and explain all possible risks and complications of treatment, and I wish to rely on the above named clinic to
exercise judgment during the course of treatment which they thinks at the time, based upon facts then known, is in my
best interests. I understand that I may refuse or stop any treatment.
By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have
been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to
ask questions. I intend this consent form to cover the entire course of treatment for my present condition and
for any future condition(s) for which I seek treatment.
X___________________________________________ X______________________________________
SIGNATURE OF PATIENT (OR REPRESENTATIVE)
DATE
SIGNATURE OF ACUPUNCTURIST
DATE
________________________________________
___________________________________________
PRINT NAME OF PATIENT (OR REPRESENTATIVE)
PRINT NAME OF ACUPUNCTURIST
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
PATIENT
INFORMATION
Date______________________________________
CONTACT INFORMATION
Name _____________________________________
Home phone _________________________________
Address ___________________________________
Work phone __________________________________
City State Zip _______________________________
Other/cell phone ______________________________
Age __________ Birthdate ____________________
Email _______________________________________
Occupation ________________________________
Another person we may contact if needed:
Company name _____________________________
Name ________________
Primary physician ___________________________
Home phone _________________________________
Physician phone number______________________
Work phone __________________________________
How did you hear about us? ___________________
Other/cell phone ______________________________
__________________________________________
Email _______________________________________
HEALTH HISTORY
What are your primary concerns for coming in for
treatment?
1- ________________________________________
2 - _______________________________________
3 - _______________________________________
How is your sleep? __________________________
__________________________________________
How is your digestion? _______________________
__________________________________________
Check symptoms you have or have had in the last
year:
□ Depression
□ Difficulty in focusing
□ Dizziness
□ Easily startled
□ Excessive worry
□ Excessive anger
□ Excessive fear
□ Fatigue/tiredness
□ Headaches
□ Loss of sleep/poor sleep
□ Loss or gain of weight
□ Nervousness/irritability
□ Overwhelmed by life
List medications or food supplements you are taking.
__________________________________________
__________________________________________
List serious illnesses, accidents or surgeries.
__________________________________________
__________________________________________
Check illnesses that have occurred in blood relatives.
Diabetes High blood pressure Stroke
Cancer Heart disease Kidney disease
2889 24th Street #A
Check conditions you have or have had in the past:
□ AIDS
□ Allergies
□ Anemia
□ Arthritis
□ Bleeding disorders
□ Breast lump
□ Cancer
□ Diabetes
How long has it been since you have had a complete
medical exam? _____________________________
San Francisco, CA 94110
415.861.0104
[email protected]
PATIENTHISTORY
INFORMATION
CONTACT INFORMATION
HEALTH
… CONTINUED
Check
symptoms
you have or have had in the last
HEALTH
HISTORY
year:
Health History Questionnaire and Registration
HEALTH HISTORY…CONTINUED
MUSCLE/JOINT/BONES
CARDIOVASCULAR
□ Chest
pain c Cramps
□ Tremors
□ Hardening
arteries
□ Swollenofjoints
□ High
or low blood
pressurein:
Pain,
weakness,
numbness
□ Pain
over
heart
□ Arms or Hips
□ Poor
circulation
□ Back
Legs
□ Previous heart attack
□ Feet
□ Rapid/irregular heart beat
□ Neck of ankles
□ Swelling
□ Hands
GASTROINTESTINAL
□ Shoulders
□ Belching,
gas or bloating
□ Other__________________
□ Colon
trouble
□ Constipation
EYES/EAR/NOSE/THROAT/RESPIRATORY
□ Diarrhea
□ Difficulty
swallowing
□ Asthma/wheezing
□ Distention
□ Blurredoforabdomen
failing vision
□ Excessive
hunger
□ Difficulty
breathing
□ Gall
bladder trouble
□ Earache
□ Hemorrhoids (piles)
□ Enlarged glands
□ Indigestion
□ Eye pain
□ Nausea
□ Frequent
colds
□ Pain
over stomach
□ Hay
fever
□ Poor
appetite
□ Hoarseness
□ Vomiting
FOR□ MEN
Gum ONLY
trouble
□ Erection
□ Nosedifficulties
bleeds
□ Penis
discharge
□ Loss of hearing
□ Prostate
trouble
□ Persistent
cough
FOR□ WOMEN
Ringing inONLY
ears
□ Bleeding between periods
□ Sinus problems
□ Clots in menses□ Previous miscarriage
SKIN
□ Boils
□ Bruise easily
□ Dry skin
□ Itching/rash
□ Sensitive skin
□ Sore won't heal
□ Sweats
GENITO/URINARY
□ Blood/pus in urine
□ Frequent urination
□ Inability to control urine
□ Kidney infection/stones
□ Lowered libido
CARDIOVASCULAR
□ Chest pain
□ Hardening of arteries
□ High or low blood pressure
□ Pain over heart
□ Poor circulation
□ Previous heart attack
□ Rapid/irregular heart beat
□ Swelling of ankles
GASTROINTESTINAL
□ Belching, gas or bloating
□ Colon trouble
□ Constipation
□ Diarrhea
□ Difficulty swallowing
□ Distention of abdomen
□ Excessive hunger
□ Gall bladder trouble
□ Hemorrhoids (piles)
□ Indigestion
□ Nausea
□ Pain over stomach
□ Poor appetite
□ Vomiting
FOR MEN ONLY
□ Erection difficulties
□ Penis discharge
□ Prostate trouble
FOR WOMEN ONLY
□ Bleeding between periods
□ Clots in menses
□ Excessive menstrual flow
□ Extreme menstrual pain
□ Irregular cycle
□ Menopausal symptoms
□ PMS
□ Previous miscarriage
□ Scanty menstrual flow
Could you be pregnant?____________
SIGNATURE
The information on this form is correct to the best of my knowledge.
Signature___________________________________________________________ Date
th
2889 24 Street #A
San Francisco, CA 94110
415.861.0104
________________
[email protected]
Our Clinic Protects Your Health Information and Privacy
Privacy Policy
Dear Valued Patient,
This notice describes our office’s policy for how medical information about you may be used and disclosed,
how you can get access to this information, and how your privacy is being protected.
In order to maintain the level of service that you expect from our office, we may need to share limited personal
medical and financial information with your insurance company¸ with Worker’s Compensation (and your
employer as well in this instance), or with other medical practitioners that you authorize.
Safeguards in place at our office include:
• Limited access to facilities where information is stored.
• Policies and procedures for handling information.
• Requirements for third parties to contractually comply with privacy laws.
• All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on
permanent file.
Types of information that we gather and use:
In administering your health care, we gather and maintain information that may include non-public personal
information.:
• About your financial transactions with us (billing transactions).
• From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone
conversations to or from other health care practitioners.
• From health care providers, insurance companies, workman’s comp and your employer, and other third
part administrators (e.g. requests for medical records, claim payment information).
In certain states, you may be able to access and correct personal information we have collected about you,
(information that can identify you - e.g. your name, address, Social Security number, etc.).
This office will not use your health information for marketing communications without your written
authorization. This office may send birthday cards, newsletters and appointment reminder, by calls, post
cards or letters.
We value our relationship, and respect your right to privacy. If you have questions about our privacy
guidelines, please call us during regular business hours at 415.861.0104.
Yours truly,
Community Acupuncture Works
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
Consent for Purposes of Treatment, Payment and Health Care Operation
I ___________________________________________(please print your name) consent to the use or disclosure of my
identifiable health information Community Acupuncture Works for the purposes of diagnosis or providing treatment to,
obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or
treatment of me by Community Acupuncture Works may be conditioned upon my consent as evidenced by my
signature on this document.
I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to
carry out treatment, payment or health care operations of the practice. Community Acupuncture Works is not required
to agree to the restrictions that I may request. However, if Community Acupuncture Works agrees to a restriction that I
request, the restriction is binding upon Community Acupuncture Works.
I have the right to revoke this consent, in writing, at any time except to the extent that Community Acupuncture Works
has taken action in reliance on this consent.
My identifiable health information means health information, including my demographic information, collected from me
and created or received by my practitioner, another health care provider, a health plan, my employer or a health care
clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or
condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review Community Acupuncture Works Notice of Privacy Practices prior to signing this
document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health
information that will occur in my treatment, payment of my bills or in the performance of health care operations of
Community Acupuncture Works. The Notice of Privacy Practices is also provided at the front desk. This Notice of
Privacy Practices also describes my rights and the duties of my practitioners and Community Acupuncture Works with
respect to my identifiable health information.
Community Acupuncture Works reserves the right to change information contained in the Notice of Privacy Practices
at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office
visit.
____________________________________________
Signature of Patient or Authorized Representative
_________________
Date
__________________________________________________________
Printed Name and Relationship
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, ___________________________, have read, reviewed, understand and agree to the statement of the
Privacy Policy for healthcare services in this office.
Patient’s Signature___________________________________
Date_______________
A copy of the Privacy Policy is available to each patient, please request one if you would like to retain a
copy for your files.
2889 24th Street #A
San Francisco, CA 94110
415.861.0104
[email protected]