Contact Pate Acupuncture and Chinese Medicine, LLC

Your initial appointment will be approximately 90 minutes long. Follow-up visits are 60 minutes.

Please make cancellations or rescheduling of appointments 24 hours in advance. A missed appointment fee of $50 will otherwise be applied.

Lisa Pate L.Ac. R.D.

Licensed Acupuncturist

Pate Acupuncture & Chinese Medicine, LLC

Address

1222 SE Division St., Portland, OR 97202

Service Area

Portland, OR

Hippa Info

Pate Acupuncture & Chinese Medicine LLC Lisa Pate L.Ac. 1222 SE Division Portland OR 97202

Consent for Purposes of Treatment, Payment & Healthcare Operations In this document “I” & “my” refer to the patient. “L.Ac.” refers Lisa Pate, L.Ac.

I consent to the use or disclosure of my protected health information by L.Ac. for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of L.Ac. I understand that the analysis, diagnosis, or treatment of me by L.Ac. may be conditioned upon my consent as evidenced by my signature below.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. L.Ac. is not required to agree to the restrictions that I may request. However, if L.Ac. agrees to a restriction that I request, the restriction is binding on L.Ac. I have the right to revoke this consent, in writing, at any time except to the extent that L.Ac. has taken action in reliance on this consent.

My Protected Health Information means health information, including my demographic information, collected from me & created or received by my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected 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 have a right to the Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices for L.Ac. is posted in the waiting room of the clinic. The Notice of Privacy Practices describes the types of uses & disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of health care operations of L.Ac. This Notice of Privacy Practices also describes my rights & duties while receiving care from the L.Ac. with respect to my protected health information.

The L.Ac. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of Privacy Practices by calling the office of L.Ac. & requesting a revised copy be sent in the mail or by asking for one at the time of my next appointment.
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Office Consent Form

Lisa Pate, L.Ac., R.D.
Pate Acupuncture & Chinese Medicine LLC
1222 SE Division St., Portland OR 97202 503.880.2785
Informed consent for Acupuncture & Oriental Medicine

I hereby voluntarily consent to receive acupuncture & Oriental Medicine treatment for my present & future health conditions. I understand that treatment will be administered by Lisa Pate, Licensed Acupuncturist (L.Ac.).
The possible acupuncture & Oriental medicine treatments that may be administered are described below.

Acupuncture: This is a safe treatment involving the insertion of tiny sterile & disposable needles through the skin. It can produce a mild, temporary sensation of warmth, tightness, soreness or tingling at the acupuncture site. It may occasionally cause slight bleeding & may rarely leave a bruise (typically not painful). Other possible risks from acupuncture include dizziness, light-headedness, & fainting. I will report to the L.Ac. any dizziness or light-headedness that occurs during or after an acupuncture treatment. Extremely rare risks with acupuncture include nerve damage, organ puncture, & infection (these have a very low incidence of occurrence).

Chinese Herbal formulas: Chinese herbs have been used safely for centuries. Infrequently one may experience digestive upset or other reactions to herbs. If I experience any discomforts related to the use of herbs, I understand that I should stop the herbs & that I am responsible for informing the L.Ac. of my symptoms.

Some herbs may be inappropriate during pregnancy & breastfeeding. I accept responsibility to inform the L.Ac. of a suspected or confirmed pregnancy, or if I am a nursing mother.

Heat treatment with moxabustion: A moxabustion stick, which is comprised of compacted mugwort is used to warm an area of the body. Every precaution is taken to prevent over warming but the rare possibility of mild burn exists.

Electro-acupuncture: A mild electric micro-current (similar to a TENS treatment) is used to stimulate the acupuncture points. A mild tingling or tapping sensation will be felt.

Cupping: This involves a localized suction produced by heating a small glass cup. There is a possibility of local bruising from the suction. Very rarely a slight burn or blister may appear due to the heat.

Gua Sha: Gua Sha is a scraping on the skin in a small area using a smooth edged instrument. This often results in bruising at the treated area. The bruising, which is not painful, usually resolves in 3-7 days.

By signing below I am showing that: -I have read, or had read to me, the information on this consent form. -I understand the possible risks & complications involved. I have had the opportunity to discuss this consent form with my Licensed Acupuncturist. I understand that I can request more information at any time if desired.

-I consent to receiving treatment that involves the above procedures. -I understand that I have the right to refuse or discontinue any treatment at any time. I understand that this refusal my affect the expected results.
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