Step 1 of 4 25% Welcome! We are very excited and look forward to working with you to achieve a superior state of health. You can count on us to assist you in accomplishing your health-related goals. We want you to achieve balance, vitality and longevity. Our staff at Tompkins Wellness Center is honored to work with you. They will do whatever is possible to make your experience here a pleasant one whether it pertains to your appointment, scheduling or otherwise. We believe the body works as a whole. We will look at your health from head to toe, so that you can achieve a better body, for a better life. We will also address mental/emotional health that is often ignored or dismissed in a patient's total health picture. Your role as a patient is to be open, honest, and ready for positive change. As someone said, “I believe the value of preventative medicine is to correct and repair imbalances before modern medicine ever names them.” It is very exciting to see people no longer needing the medications they once needed as a result of the repair and long-term correction the body has made as a result of proper fortification and intervention. It is our pleasure to welcome you to our office. It’s amazing how the body is capable of healing! Let’s expect and anticipate measurable changes as we work together to accomplish your health-related goals! Yours in health, Dr. Tompkins and Staff Date(Required) MM slash DD slash YYYY Confidential Patient Health InformationPersonal History Name(Required) Full Name Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Home Phone(Required)Birth Date(Required) MM slash DD slash YYYY Sex(Required) Male Female Age(Required) Cell Phone(Required)Married Yes No Single Yes No Widowed Yes No Divorced Yes No Separated Yes No Business Employer Type of Work Business PhoneDriver’s License Name and Ages of ChildrenReferred to this office by Name of Emergency Contact(Required) Full Address of Emergency Contact(Required)Who is responsible for payment(Required) Current Health ConditionUnwanted Health Condition(Required) Other Doctors Seen For This Condition(Required) Type of Treatment Results When Did This Condition Begin? Is Condition Job Related Accident Home Injury Fall Other Drugs You Now Take Nerve Pill Painkillers/Muscle Relaxers Insulin Vitamins Herbs Supplements Blood Pressure Medicines Other Do You Wear a Shoe Lift? Yes No Do You Suffer From Any Condition Other Than That Which You Are Now Consulting Us? Past Health History Please Check and Describe Major Surgery/Operations Appendectomy Tonsillectomy Gall Bladder Hernia Back Broken Bones Other Major Accidents/Falls Hospitalizations other than above Previous Chiropractic Care None Doctor’s Name and Date of Last Visit Doctor’s Name and Date of Last Visit Below are a list of diseases which may be unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care. CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD: Pneumonia Mumps Influenza Rheumatic Fever Small Pox Pleurisy Polio Chicken Pox Arthritis Tuberculosis Diabetes Epilepsy Whooping Cough Cancer Mental Disorders Anemia Heart Disease Lumbago Measles Thyroid Eczema INTAKE Coffee Tea Alcohol Cigarettes White Sugar Have you been tested HIV positive? Yes No CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS:MUSCULO-SKELETAL Low Back Pain Gas/Bloating After Meals Pain Between Shoulders Heartburn Neck Pain Black/Bloody Stool Arm Pain Colitis Joint Pain/Stiffness Walking Problems Difficulty Chewing/Clicking Jaw General Stiffness FEMALES ONLY:When was your last period? Are you Pregnant? Yes No Not sure GENITO-URINARY Bladder Trouble Painful/Excessive Urination Discolored Urine NERVOUS SYSTEM Nervous Numbness Paralysis Dizziness Forgetfulness Confusion/Depression Fainting Convulsions Cold/Tingling Extremities Stress C-V-R Chest Pain Short Breath Blood Pressure Problems Irregular Heartbeat Heart Problems Lung Problems/Congestion Varicose Veins Ankle Swelling Stroke GENERAL Fatigue Allergies Loss of Sleep Fever Headaches EENT Vision Problems Dental Problems Sore Throat : Earaches Hearing Difficulty Stuffed Nose GASTROINTESTINAL Poor/Excessive Appetite Excessive Thirst Frequent Nausea Vomiting Diarrhea Constipation Hemorrhoids Liver Problems Gallbladder Problems Weight Trouble Abdominal Cramps MALE/FEMALE Menstrual Irregularity Menstrual Cramps Vaginal Pain/Infection Breast Pain/Lumps Prostate/Sexual Dysfunction Other Problems Mention Other Problems FAMILY HISTORY The Following members have a same or similar problem as i do Mother Father Brother Sister Spouse Child THE FOLLOWING SECTION IS FOR THE PATIENT TO READ AND SIGNTompkins Wellness Center Policies Payment of Bills Payment is due at time of service or when supplements are ordered. We will expect you to honor the financial agreements you make with our office. If you find that you cannot fulfill the agreement you have made with us or are unable financially to make the payments for services rendered, advise our staff immediately so new arrangements can be made. If you choose not to make payments to our office for the balance owed, we will report your outstanding balancer to the credit bureau and a collection agency. If legal action is required, you will be responsible for the balance owed to our office as well as any legal fees incurred by Tompkins Wellness Center. Inc. Insurance We do not file with any insurance company unless due to Medicare. However upon request, we do provide the necessary codes on a “super bill” which you can submit to your insurance company for reimbursement. Super bills can be provided up to 90 days prior to the request date. Worker’s compensation It is our policy to not become involved in Personal Injury lawsuits or Worker’s Compensations claims. Nor will we voluntarily become involved in litigation on behalf of a patient in these types of claims or lawsuits. Cell Phones Please be courteous to others and turn off all cell phones. Perfumes and Colognes We do treat patients with severe allergies to scents. We ask that you please refrain from wearing any strong scents while entering our office. Supplements It is our goal to provide sustainable nutritional support. We track and monitor inventory to ensure proper availability to the best of our ability. In order to do so we encourage patients to take full responsibility of supplements purchased and ordered. Unopened and unexpired supplements can be returned for full credit within 30 days of purchase. **Cancellations In order for you to receive the best results, we strongly encourage all appointment times to be kept. Missing appointments results in a slower and ultimately more costly recovery. If, for any reason, you are unable to keep an appointment time, we require at least 24 hours notice. If less than 24 hours notice is given, we will need to charge a $35.00 fee, and for no shows the full price of the missed appointment. We provide a free text reminder service to your cell phone and email address. Please understand that this service is a courtesy and not receiving one, does not exempt you from this policy. Name(Required) Full Name Date(Required) MM slash DD slash YYYY Informed Consent for Acupuncture TreatmentConsent 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 may present condition and for any future condition(s) for which I seek treatment.I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures, including various modes of physiotherapy on me (or the patient named below, for whom I am legally responsible) by the acupuncturist named below and/or other licensed acupuncturists who now or in the future treat me while working or associated with, or serving as a back-up for the acupuncturist named below, including those working at this or any other office, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping & gua sha, electrical stimulation, breathing techniques, exercise therapy Tui-Na (Chinese massage), Chinese or western herbal medicine, and nutritional counseling. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Bruising is a common side effect of cupping and gua sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist below uses sterile, disposable needles, and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, mineral, and animal sources) that have been recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I understand that the herbs need to be consumed according to the instructions provided orally and in writing. I understand that some herbs may have an unpleasant taste or smell. I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs. I will notify the acupuncturist who is caring for me if I am, or become pregnant. I do not expect the acupuncturist to be able to anticipate and explaining all possible risks and complications of treatment, and I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. Name of Patient(Required) Full Name Name of Acupuncturist Full Name Name of Patient / Representative(Required) Full Name Name of Witness/Translator Full Name Date Consent Completed(Required) MM slash DD slash YYYY Tompkins Wellness CenterPrice List New Patient Exam $175 Re-Exam $65 Adjustment-Adult $55 Acupuncture Only $50 Acupuncture with Adjustment $90 Nutritional Test $50 Office Visit $50 Emotional Release Treatment $55 Parasite Elimination Technique $50 Urinalysis $25 NAET Treatment $55 Office Fees Return Check Fee $35 Same Day Cancellation Fee $35 No Show Subject to appt fee missed I have been shown the price list and understand payment is due when services are rendered.Name(Required) Full Name Date(Required) MM slash DD slash YYYY Medical Information Release FormHIPAA Release FormName(Required) Full Name Date of Birth(Required) MM slash DD slash YYYY Release of Information I authorize the release of information including the diagnosis, records; Examination rendered to me and claims information. This information may be released to: Spouse Child(ren) Other Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing.MessagesPlease call my home my work my cell number If unable to reach me You may leave a detailed message Please leave a message asking me to return your call Message The best time to reach me is (day) between (time) Name/Signed(Required) Full Name Date(Required) MM slash DD slash YYYY Witness Full Name Date MM slash DD slash YYYY