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PATI E NT REG I STR ATI ON FO RM confidential patient information

PERSONAL INFORMATION
Name: DOB: / / Sex: M F
Address: City: State: Zip:
Email: Cell/Home:
Work Phone: What phone do you prefer to be reached at?
Do you authorize voice mails at this number? Y N Social Security #:
Marital Status: (circle) Married Single Partner Widowed Dependent Other:
Do you have children? Y N If so, How many dependents? Occupation:
Employer: Drivers Lic #: State:

FAMILY
Spouse/Partner Name: Home/Cell Phone:
Occupation: Spouse/Partner Employer:
Work Phone: Email:

EMERGENCY CONTACT
Emergency Contact Name: Relationship:
Home/Cell Phone: Work Phone:

HEALTH CARE PROVIDERS

Family Physician: Clinic Name:
Address: City: State: Zip:
Phone: Is this your referring provider? Y N

PRIMARY INSUR ANCE INFORMATION

Insurance Company: Phone:
Address: City: State: Zip:
Subscriber Name: Relationship: DOB: / /
Employer of Insured:
ID# as shown on the card: Group#:

SECONDARY INSUR ANCE INFORMATION

Is this visit injur y related? Y N Work Related? Y N Auto Accident: Y N
Date of Injur y: / / State of Accident:
Insurance Injur y: Phone:
Address: City: State: Zip:
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H E ALTH & WE LLN E SS I N FO RMATI O N confidential patient information

PRESENT ILLNESS
What is your chief complaint?
When did this condition begin?
Has a diagnosis already been made by a health care practitioner? If so, what was the diagnosis, and who made it?

What treatments have you already received?

Who referred you?

Have you had imaging done? Y N What forms?

On the diagram below, please indicate the areas in which you experience discomfort .
If the discomfort radiates, please draw arrows to indicate which direction.

Please rate your discomfort today: (10=most) 0 1 2 3 4 5 6 7 8 9 10

Please describe your discomfort:
Does heat/cold alleviate symptoms: Y N
Is discomfort alleviated with pressure? Y N
Does discomfort migrate to different areas of your body? Y N
Does weather affect your discomfort? Describe:
MEDICAL HISTORY
Date of Most Recent Physical Exam: / / Physician:
Histor y of Serious Illness(es)? Please list:

What surgeries/traumas have you had? When did they occur?

Allergies and Sensitivities: (please list)

WOMENS HEALTH
Date of Last Menstrual Cycle: / / Are you Pregnant? Y N If so, how many?
Live Birth(s) Miscarriage: If so, how many? Do you plan on becoming Pregnant? Y N
Have you been diagnosed with a g ynecological condition? Y N Please list:

MEDICAL CONDITIONS
Please indicate if you have EVER had any of the following:

Asthma Kidney Disease Anemia or Other Blood Disorder

Seasonal Allergies Kidney Stones
Pneumonia Bleeding Disorder
Respiratory Infection Cancer (Specify)
Emphysema Unusual Bleeding or Discharge
Tuberculosis Jaundice
Whooping Cough Rheumatic Fever
Hoarseness Stroke Disorder of the Genitalia
Difficulty Swallowing Heart Attack Gynecological Disorder
Thyroid Disorder Cardiac Pacemaker and/or Defibrillator Sexually Transmitted Infection
Hepatitis A / B / C
Congenital Abnormalities Urinary Bladder Problems/Infections History of Sexually Transmitted Disease
Diabetes Mellitus Frequent or Painful Urination HIV or AIDS
Diabetes Insipidus Prostate Problems
Sderoderma Skin Rashes or Diseases
Epstein Barr Virus (EBV) Erectile Dysfunction
Cytomegalovirus (CMV) Obvious change in Wart or Mole
Lupus Erythmatosis (SLE) Peptic Ulcer Shingles
Gastric Ulcer Balance of Gait Problems
Fibromyalgia Pancreatitis Vision Changes
Peripheral Neuropathy Acid Reflux Disorder of the Eye
Rheumatoid Arthritis
Osteoarthritis Colitis
Crohn’s Disease Surgical Implants
Epilepsy or Seizure Disorder Irritable Bowel Syndrome Unexplained Weight Loss/Gain
Heart Disease Gallstones Depression
High Blood Pressure Gallbladder Disease Anxiety
BP / Hernia Alcohol/Drug Abuse
Low Blood Pressure Hemorrhoids Other
/ Change in Bowel or Bladder Habits
Fainting/Dizziness Blood in Stool
Tinnitus
MEDICATIONS
Please list all medications including prescriptions, over-the-counter, and herbal or vitamin supplements.
Medication/Supplement (please include dosage) Start Date

ALLERGIES TO MEDICATIONS/SUPPLEMENT

SOCIAL HISTORY
Do you Exercise? Y N How often? What Activities?
What’s your Stress Level? (10=most) 0 1 2 3 4 5 6 7 8 9 10
What Triggers your Stress?
How is your Energ y Level? (10=most) 0 1 2 3 4 5 6 7 8 9 10
What time of the day do you have the most energ y?
Do you struggle with Anxiety or Depression? Y N If so, what?
Do you have Difficulty Sleeping? Y N Which of the Following? Staying Asleep Falling Asleep
Waking Refreshed Racing Mind Pain Frequent Urination Hot Flashes Other
What is your Sexual Orientation? What is your Gender Identity? Are you Sexually Active? Y N
Do you Smoke? Y N How many Cigarettes per day? If yes, do you want help Quitting? Y N
Do you drink Alcohol? Y N How often? (drinks per week)
Do you use recreational drugs? Y N How often/type?
FAMILY HEALTH HISTORY
Please list significant diseases and health conditions of family members:

SIGNATURE
Thank you for completing the above information. This information will provide me with an accurate first assessment of your overall
health. Please print your name, sign, and date if you agree the above information is true to the best of your knowledge.

Patient Name:

Signature: Date:

Representative’s Name:

Representative’s Signature: Date:

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CLI N I C PO LI CI E S
PAYMENT
I understand payment is due at the time-of-service. Cash or credit cards are the only acceptable forms of payment.

INSUR ANCE
If I wish to bill my insurance I understand insurance policies may vary greatly in terms of deductible and percentage of coverage for services
at this clinic. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the
payment of your deductibles, copays, as well as any unpaid balances in this office.
We will do our best to verity your insurance coverage, and will bill your insurance in a timely manner. If your insurance carrier sends payments to
you for services rendered in this office, you agree to send or bring those payments to this office upon receipt. If you pay for your visits in full, then
the payments should be sent directly to you from the insurance company. If your insurance carrier sends payments to you for services rendered in
this office, you agree to send or bring those payments to this office upon receipt. If your insurance company requires medical reports or records
to document your treatment or progress, your signature below authorizes this office to release the medical information necessary to process your
claim.
I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Policy. I understand that if I have questions or complaints
regarding my privacy rights that I may contact the office. I further understand that the practice will offer me updates to this Notice of Privacy
Policy should it be amended, modified, or changed in any way.

CANCELL ATION/L ATE ARRIVAL POLICY

As courtesy to other patients, I am aware that a specific amount of time has been set aside for my treatment. Arriving late means that my
treatment will be adjusted to fit into the time scheduled. I will give 24-hour notice of intent to cancel or reschedule my appointment, except in
case of emergencies. Missed appointments will be charged a cancellation fee of $45. Late cancellation of an off-site treatment will be charged
$250 per event.

HEALTH CONDITIONS
I understand I must report all past and pre-existing health conditions to my health practitioner. I understand it is my responsibility to report any
changes or updates with my health. I also will notify my practitioner of any past surgeries, surgical implants and/or cardiac pacemakers prior to
treatment. The patient must inform the East Asian medicine practitioner if the patient has a severe bleeding disorder or pacemaker prior to any
treatment.

PREGNANCY
I understand that I am required to report if I suspect, am planning or am currently pregnant to my health practitioner prior to treatment.
I understand the risks and will take responsibility if I fail to do so.

MEDICATIONS AND SUPPLEMENTS

I understand the importance of reporting all medications, supplements, herbs and vitamins to my health practitioner. I promise to report all
current medications/vitamins/supplements/herbs. I will update the practitioner if any of this change during the course of treatment including
dosage/frequency of each. I understand the risks of drug/herb interactions and efficacy if I fail to do so.

ELECTRONIC COMMUNICATION DISCLOSURE

While the clinic strives to maintain security, the electronic system including email, text and messaging services by Thrive Integrative Health
are not encrypted and so does not adhere to HIPAA standards. You may choose to opt out of receiving alerts with personal health information.
Check here if you wish to opt out

With this knowledge,I consent to the above policies, procedures and assume all financial responsibility. I have been given the
opportunity to ask questions clarif ying its contents.

Patient Name:

Signature: Date:

Representative’s Name:

Representative’s Signature: Date:

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N OTI CE OF PRIVACY P OLI CY

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.

OUR RESPONSIBILITIES
The law protects the privacy of the health information we create and obtain in providing care and services to you. For example, your protected
health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and
payment information related to these services. Federal and state laws allow us to use and disclose your protected health information for purposes
of treatment, payment, and health care operations.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

For Treatment: Information obtained by a licensed provider or other member of our healthcare team will be recorded in your medical record and
used to help decide what care may be right for you. For example, your physician may need to consult with specialists about your care. Information
about you would be shared with other providers to help understand your care needs.
For Payment: When we request payment from your health plan or other payers, they need information from us about your medical care such as
diagnoses, procedures performed, or recommended care in order to cover the services provided to you. For example, we may need to give your
health plan information about your therapy you received so your health plan will pay us or reimburse you for the procedure. We will not disclose
your health information to third party payers without your authorization unless allowed to do so by law.
For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are
necessary to make sure that all of our patients receive quality care. For example:
• We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
• We may disclose information to physicians, student clinicians, medical assistants, technicians, or other clinic personnel for review and
learning purposes.
• We may use and disclose your information to conduct or arrange for services, including medical quality reviews; accounting, legal, risk
management and insurance services; and audit functions, including fraud and abuse detection and compliance programs.

OTHER USES AND DISCLOSURES

Clinic Directory: Unless you notify us that you object, we may use your name, location in the facility, and general condition for directory
purposes. Directory information may be provided to people who ask about you by name. This information also includes your appointment dates.
No medical information, including your chief complaint or the nature of your care, will be disclosed as part of directory information.
Communication with Family and Friends: We may release medical information about you to a family member or friend who is involved in your
care and/or helps pay for your care. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your
family can be notified about your condition, status, and location.
Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical care at our clinic.
Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat
to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to
prevent the threat.

SPECIAL SITUATIONS
Organ and Tissue Donation: If you are an organ donor, we may release medical information as necessary to facilitate organ or tissue donation and
transplantation to organizations that handle organ or tissue procurement and transplantation or to an organ donation bank.
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command
authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide
benefits for work-related injuries or illnesses.
Public Health: As required by law, we may disclose medical information about you to public health or legal authorities charged with preventing or
controlling disease, injury, or disability.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight
activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor
the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or
administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process
by someone else involved in the dispute.
Law Enforcement: We may release medical information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at our clinic;
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who
committed the crime.
Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of
the hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information
about you to the correctional institution or law enforcement official necessary for your health and the health and safety of other individuals.

YOUR HEALTH INFORMATION RIGHTS

Right to this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy at any time.
Right to Inspect and Copy: You have a right to inspect and receive a copy of certain health care information including certain medical and billing
records. To obtain a copy of your records you must submit your request in writing on an official authorization form to Thrive Integrative Health. If
you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you
would like to schedule an appointment to view your record or if you have any questions about your right to inspect and copy your record.
Note: We are required to retain our records of the care that we provided to you. Although you have the right to exercise control over certain uses
and disclosures of your medical information, the medical record maintains on your care is property of Thrive Integrative Health may deny your
request to inspect and copy in certain limited circumstances. If you are denied access to your medical record, you may request that the denial be
reviewed. We will comply with the outcome of the review.
Right to Request Amendment: You have a right to ask that your health information be amended by sending a written request. We have the
right to deny this request under certain circumstances. You may write a statement of disagreement if your request is denied. This statement of
disagreement will be stored in your medical record, and included with any release of your records.
Right to a List of Disclosures: You have the right to request a list of disclosures. This is a record of certain disclosures we made of medical
information about you in accordance with applicable laws.
You must submit your request in writing to our to obtain a list of disclosures. The first time you request a list within a 12 month period will be free
of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to
withdraw or modify your request at that time before any costs are incurred.
Right to Request Restriction: You have a right to ask us to restrict certain uses and disclosures of your health information. You may be asked to
make this request in writing. Ask your caregiver if you have questions about this. We will comply with all reasonable requests.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a specific
way or location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may be asked
to make your request in writing. Ask the person (or department) that gave you this notice for more information about this process. We will comply
with all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Revoke Authorization: Other uses and disclosures of your health information not covered by this notice or the laws that apply to us
will be made only with your written permission. If you provide us with permission to use or disclose health information about you under these
circumstances, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical
information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we
have already made with your permission, and information disclosed to other party’s may no longer be afforded certain protections under the law
once released and might be re-disclosed to other parties without your authorization.
Changes to this Notice: We reserve the right to change this notice at any time. Any revised or changed notice will be effective for medical
information we already have about you as well as any information we receive in the future.
Complaints: If you believe your privacy rights have been violated, you may contact Thrive Integrative Health. You may also file a complaint with
the Secretary of the U.S. Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for
filing a complaint.
Thrive Integrative Health records health care services we provide you. You may ask to see and copy of your record. You may ask to correct the
record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. You may see
your record or get more information by contacting Engracia Tharp.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

Patient Name:

Signature: Date:

Representative’s Name:

Representative’s Signature: Date:

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CONS E NT TO TRE AT
East Asian medicine means a health care service using East Asian medicine diagnosis and treatment to promote health and treat organic or
functional disorders. I, the undersigned, hereby authorize Engracia Tharp, EAMP / Carsten Rode, EAMP / Jonathan Day, EAMP at
Thrive Integrative Health (qualifications below) to perform the following specific procedures:

ENG R ACIA THARP ’S QUALIFICATIONS : CARSTEN RODE ’S QUALIFICATIONS: JONATHAN DAY ’S QUALIFICATIONS:
• Clinical and didactic training was completed at • Clinical and didactic training was completed at • Clinical and didactic training was completed at
Bastyr University, Kenmore Washington. Bastyr University, Kenmore Washington. Bastyr University, Kenmore Washington.

• Masters of Science degree in Acupuncture and • Masters of Science degree in Acupuncture, May 2014 • Masters of Science degree in Acupuncture and
Oriental Medicine, December 2013 • Washington State Department Health license Oriental Medicine, December 2014

• Washington State Department Health license # AC60497362 • Washington State Department Health license
# AC60434405 • Diplomate of Acupuncture (NCCAOM) # AC60530821

• Diplomat of Oriental Medicine (NCCAOM) • Diplomat of Oriental Medicine (NCCAOM)

As outlined in the legal scope of practice of licensed acupuncturists in Washington state (RCW 18.06, WAC 246.802),
I understand that these methods of treatment may include but are not limited to the following:

EAST ASIAN MEDICINE SCOPE OF PR ACTICE:

The scope of practice for an acupuncturist in the state of Washington includes but is not limited to the following techniques:
• Acupuncture: use of acupuncture needles or lancets to directly or indirectly stimulates acupuncture points and meridians
• Electroacupuncture: the use of electrical, mechanical or magnetic devices to stimulate acupuncture points and meridians
• Moxibustion: heating a specific acupuncture point or area by burning an herb or herbal formula
• Acupressure: manual therapy on acupuncture points
• Cupping: glass or plastic cups placed on the skin using heat or mechanical means to create a vacuum
• Gua Sha: dermal friction caused by scraping the skin with a blunt object
• Infa-red heat therapy: therapeutic heat lamp
• Superficial heat and cold therapies: icing and heat applied to superficial fascia
• Sonopuncture: tuning forks, singing bowls
• Point injection therapy (aquapuncture)
• Laserpuncture: stimulation of acupuncture points with laser light
• Nutrition: Dietary advice and health education based on East Asian medical theory, Chinese herbal formulas, vitamins and supplements:
including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements
• Meditation: Breathing, relaxation, and East Asian exercise techniques; Qi gong
• East Asian Massage and Tui na: a method of East Asian bodywork, characterized by the kneading, pressing, pushing, rolling, shaking, and
stretching of the body and does not include spinal manipulation.

I recognize the potential risks of these procedures described below, which include but are not limited to:
Potential Benefits: Drugless relief of presenting symptoms and improved balance of body energies that may lead to the prevention, improvement
or elimination of the presenting problem.
Side Effects: The following side effects may occur and are not limited to the following: some pain, numbness, tingling; minor bleeding; minor
bruising; blistering, skin discoloration; aggravation of symptoms prior to acupuncture treatment; minor burns; infection; needle sickness:
feeling faint or dizzy; fainting, vomiting. Unusual risks include, but not limited to: broken needle, spontaneous miscarriage, nerve damage, and
organ puncture, including pneumothorax. Herbal side effects may occur and are not limited to: nausea, appetite decrease/increase, heartburn,
abdominal distention, gas, increased bowel movements, diarrhea, constipation, increase or decrease in blood pressure, insomnia, and/or
increased urination.
I recognize that some herbal supplements may interact with medications and I will consult my primar y care physician prior to beginning herbal treatment. With
this knowledge, I voluntarily consent to the above procedures and policies. I have been given the opportunity to ask questions clarif ying its contents realizing that
no guarantee have been given to me by Engracia Tharp / Carsten Rode / Jonathan Day at Thrive Integrative Health regarding cure or improvement of my condition.
I hereby release Engracia Tharp, Carsten Rode, Jonathan Day and Thrive Integrative Health from any and all liability that may occur in connection with the above-
mentioned procedures except for failure to perform those procedures with appropriate medical care. I understand I am free to withdraw this consent and discontinue
participation in these procedures at any time. If a referral is required in order for me to be seen in this office, I am responsible for making sure all referrals are current.

Patient Name:

Signature: Date:

Representative’s Name:

Representative’s Signature: Date: