New Patient Intake Form – Soliman Auricular Allergy Treatment (SAAT)New Patient Intake Form – Soliman Auricular Allergy Treatment (SAAT) Dr. Joe Linza, D.C., FIAMA 1718 Memorial Drive Clarksville, TN 37043 Phone: (931) 444-5955 / Fax: (931) 444-3947New Patient Intake Form – Soliman Auricular Allergy Treatment (SAAT)Please complete this form as accurately as possible. All information is confidential.Patient Information Full Name: * Date of Birth: * Age: Sex: * MaleFemale Phone Number: * Email * Address: * City: * State: ZIP: Emergency Contact Name: * Relationship: * Phone * Primary Reason for Visit What symptoms or conditions are you seeking SAAT treatment for? * When did your symptoms begin? Have you been formally diagnosed with any allergies? * Yes No If yes, please list them: Have you undergone allergy testing? * Yes No If yes, please list the allergie(s) you were diagnosed with: Skin testing Blood testing OtherOther Date of testing: What previous treatments have you tried (e.g., medications, avoidance, acupuncture, immunotherapy)? Health HistoryPlease check any of the following conditions that apply to you (past or present): Asthma Eczema Hay Fever Food Allergies Drug Allergies Anaphylaxis Anxiety/Depression Heart Disease Diabetes High Blood Pressure Seizures Other (please specify):Other (please specify): List any current medications (including supplements): Do you have any implanted medical devices (e.g., pacemaker, cochlear implant)? Yes No If yes, please describe: SAAT-Specific Information Are there any specific allergens you are hoping to address (e.g., alpha-gal, pollen, mold, foods)? Have you received SAAT treatment before? Yes No If yes, when and for what allergen(s)? Do you have any metal allergies or sensitivities? (e.g., to surgical steel, stainless steel) Yes NoLifestyle & Other ConsiderationsDo you smoke? Yes NoDo you consume alcohol? Yes No Do you follow any special diet (e.g., gluten-free, vegan)? Are you pregnant or planning to become pregnant? Yes No NAConsent & SignatureBy signing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that SAAT is considered an alternative/complementary therapy and is not a substitute for conventional medical treatment. I consent to undergo SAAT treatment and understand the potential risks and benefits as explained to me. Signature signature keyboard Clear Date SAAT TreatmentSAAT Treatment DescriptionSoliman Auricular Allergy Treatment (SAAT) is a specialized acupuncture technique used to address allergies. It involves placing a single needle in a specific ear point to stimulate the body’s natural healing response which may alleviate allergy symptoms. SAAT aims to reduce or eliminate reactions to specific allergens. SAAT is considered a minimally invasive and drug-free approach to allergy treatment.SAAT Treatment ProcessThe consultation, testing, and treatment will be completed at the initial visit, unless the testing indicates that the individual is allergic to anything that will be used on the ear for treatment purposes. While the treatment itself takes very little time, we allow up to 45 minutes for your initial appointment to address questions and concerns you may have. Treatment will not take place at the initial visit for patients whose in-office testing indicates they will be allergic to the needles or to the adhesive used to secure the needles to the ear.If in-office testing indicates that you are reactive to either metal or adhesives, you will need to take oral remedies at home at your expense and return for treatment at a later date.Previous allergy testing is not required prior to having treatment at our office, as testing is done in-office. Our in-office testing does not include blood tests or skin prick tests. It involves a very easy and non-invasive form of neuromuscular testing. If you have test results from another clinic you are welcome to bring them.The treatment process involves the insertion of tiny (3mm) needles into the right ear. The left ear is only used if the right ear is unable to be used for needling purposes. Each needle is covered by a small piece of medical adhesive and is left in the ear for three to four weeks, depending on the individual.Patients must return for a follow-up. This is done after the needles have been removed. Needles are typically removed at home by the individual but can be removed in-office if preferred.Patients will then re-expose to the treated items per instructions given by the practitioner.Patients who have had true anaphylactic shock will not be given re-exposure instructions. In these cases, the purpose of the treatment is to no longer have reactions to lesser forms of exposure, such as fumes and cross contamination.PricingThe cost of the initial consultation, testing, and treatment with one recheck that does not involve additional protocols is $400.The initial treatment price may be more depending on what the testing shows at the initial visit. Pre-treatment is required if testing indicates you are reactive to either the adhesives or metal used on the ear. Oral remedies will need to be used at home for an additional cost, for at least 6 weeks prior to returning for treatment. In some cases, remedies are also required to fully address the allergens.There will be an additional fee if additional protocols are required. An office visit for additional protocols is $250. The cost for the oral remedies will vary depending upon the allergies being addressed, but can range from $78 up to $155, and may require more than one at a time.A non-refundable deposit of $150 is required to book an appointment. The $150 non-refundable deposit will be applied to the total due at the initial visit. Your credit card will be kept on file to charge the initial deposit, and to collect the balance at your first appointment.A very specific appointment time slot is scheduled for SAAT. If you do not show up for your appointment, your $150 deposit will be forfeited, and you will lose the ability to schedule future appointments.Please arrive 10 minutes early for your appointment.If you need to reschedule your appointment, you must call the office a minimum of 24 hours prior to your appointment time. If the office is closed, you must leave a message on the office voicemail. When we are back in the office, we will call you to reschedule the appointment. You will be given 1 opportunity to reschedule an SAAT appointment. After the first reschedule, if you do not show or reschedule your second appointment time, you will forfeit your $150 deposit and will lose the ability to make future appointments.Due to scheduling restraints, if you will be up to 5 minutes late for your appointment, you must call the office immediately to see if we still have availability. If we are unable to accommodate you due to being late, you will be given one opportunity to reschedule that appointment time, and it will be subject to our clinic’s availability. If you cannot reschedule, your deposit will be forfeited. I have read and understand the SAAT Treatment form. I give KnowBull Chiropractic permission to collect a $150 non-refundable deposit, to keep my credit card on file, and to charge this card in order to collect any balance due. I confirm that I have read and understood the HIPAA Privacy Policy . I consent to the handling of my information in accordance with that policy. * Signature signature keyboard Clear Date Use of Patient Health Information (PHI)KnowBull Chiropractic wants you, the Patient, to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care treatment, we must require you to read and sign this consent form stating you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA Notice that is available to you at the front desk, before signing this consent.You understand and agree to allow this chiropractic office to use your Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, you agree to allow this office to submit requested PHI to any health insurance companies that you use for the purpose of payment. Be assured that this office will always limit the release of all PHI to the minimum needed for what the insurance companies require for payment.You have the right to examine and obtain a copy of your own health records at any time. You may request to know what disclosures have been made and submit in writing any further restrictions on the use of your PHI. This office is obligated to agree to those restrictions only to the extent they coincide with state and federal law.Your written consent needs to be obtained and only one time for all subsequent care given.You may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request is signed.KnowBull Chiropractic may contact you periodically regarding appointments, treatments, products, and services performed by our office. You may choose to opt out of any marketing communications at any time by letting us know in writing.For your security and right to privacy, all staff at KnowBull Chiropractic have been trained in patient record privacy, and a privacy official has been designated to enforce those procedures in our office. We take all precautions to ensure that your records are not readily available to those who do not need them.You have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures without retaliation by this office.Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains. You will be provided with a new notice on your next visit following any change.This notice is effective on the date signed below.If you refuse to sign this consent for the purpose of treatment, payment, and health care operations, the physicians in this office have the right to refuse care. Signature signature keyboard Clear Date HIPAA Notice of Privacy PracticesKnowBull Chiropractic1718 Memorial Drive, Clarksville, TN 37043-4542This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.Our ObligationsWe are required by law to:Maintain the privacy of protected health informationGive you notice of your legal duties and privacy practices regarding health information about youFollow the terms of our notice that is currently in effectHow We May Use and Disclose Health InformationExcept for the following purposes, we will use and disclose health information only with your written permission.Treatment – Sharing with professionals involved in your medical care.Payment – For billing and payment purposes.Health Care Operations – For office management and quality assurance.Reminders and Services – To contact you about appointments or services.Individuals Involved in Your Care – When appropriate, to family or others involved.Research – Only under approved circumstances.Special SituationsAs required by lawTo prevent a serious threat to health or safetyTo business associatesOrgan and tissue donationMilitary and veteransWorker’s compensationPublic health and oversight activitiesLawsuits and disputesLaw enforcementCoroners, funeral directors, and medical examinersNational security and intelligence activitiesInmates or individuals in custodyYour RightsInspect and Copy – You may request access to your records.Amend – Request corrections to your records.Accounting of Disclosures – Request a list of disclosures.Request Restrictions – Limit what we use or share.Confidential Communications – Choose how we contact you.Paper Copy – Request a printed version of this notice at any time.Changes to This NoticeWe reserve the right to change this notice and make it apply to all health information we already have. You will receive a new notice at your next visit if any changes are made.ComplaintsIf you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. Signature signature keyboard Clear Date Submit If you are human, leave this field blank.