New Patient Intake Form – Soliman Auricular Allergy Treatment (SAAT) - KnowBull Chiropractic and Medical Acupuncture

Dr. Joe Linza, D.C., FIAMA
1718 Memorial Drive
Clarksville, TN 37043
Phone: (931) 444-5955 / Fax: (931) 444-3947

New 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:

Male

Female

Preferred Pronouns:

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 History

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

No

Lifestyle & Other Considerations

Do you smoke?

Yes

No

Do 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

NA

Consent & Signature

By 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.

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SAAT Treatment

SAAT Treatment Description

Soliman 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 Process

The 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.

Pricing

The 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.

SAAT Scheduling Process

Go to our website: https://knowbullchiropractic.com/patient-forms/, and complete the new patient intake.
Print these forms (3 pages), complete, and email to our office: knowbullchiropractic@gmail.com.
Once we receive both your intake and these signed forms, we will call you to schedule an appointment and collect your $150 deposit. As a reminder, your credit card will be kept on file.

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.

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New Patient Intake Form – Soliman Auricular Allergy Treatment (SAAT)