New Client Male

All About Herbs

Thermal Imaging New Client Intake Form
Name*
Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email address*
example@example.com
How did you hear about us
Symptoms & History
Age*
Gender
Primary Care Physician
Referring Physician
Current Concerns*
Current Symptoms*
Current Treatments*
Current Prescription Medication(s)*
Have you had a thermogram at All About Herbs before?*
If yes, was there recommendations to follow up with your doctor?
If yes, did you and what was the outcome?
Please list any surgeries you have had with date, (just the year is fine):*
Dental History, check all that apply?*

amalgamfillingsroot canalsbridgescrownsperiodontal diseaseOther
Would you describe your general health as good, fair, or have concerns?*
Please list immediate family health history, include family member and disease (example: father, heart disease).*
Do you have any medical diagnoses?*
Do you have any skin lesions or physical abnormalities in the area we will be scanning?*
(Female Patient Only)
Do you have any abnormal Ob/Gyn History?
Is there anything else you would feel is important for us to note?
Disclaimer
The Thermal Imaging report is designed to support, NOT REPLACE, the relationship that exists between you and your Physician. It is a procedure that can alert your doctor to changes that may indicate early disease. It is not intended to replace the Medical Advice of your doctor or licensed medical provider. It is not intended to treat, or cure any ailment you may or may not have.

The information contained within the report is to be used for informational and educational purposes only. Please consult your healthcare provider for advice about a specific medical condition.

Furthermore, you are being assisted by a Certified Clinical Thermographer who IS NOT A LICENSED PHYSICIAN.
- Any questions discussed in context to the generated report IS NOT A DIAGNOSIS.
- Any health related information shared between persons IS NOT MEDICAL ADVICE AND SHOULD NOT BE
CONSULT YOUR PHYSICIAN WITH MEDICAL INQUIRIES OR SPECIFIC DIAGNOSIS RELATED QUESTIONS.
Printed name*
Date*

MonthDayYear
Date
Signature*

Clear
All About Herbs

Notice of Privacy Practices
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.

All About Herbs is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

We only submit your health information to EMI for the sole purpose of interpreting you thermal scans.

We only submit your EMI Report to you at the mailing or email address you have provided.

We do not share your information with anyone else, unless we are required to do so by law.

Marketing and Contact.

As a courtesy we may contact you via telephone, text message or email to remind you of your appointment, or to remind you to make a follow up/annual appointment. We will not include any personal health information in these messages.

We will not use your information for any marketing, unless you request to be on our newsletter email list.

Change of Ownership.

In the event that All About Herbs is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that All About Herbs is not required to agree to the restriction that you requested.
- You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
- You have the right to inspect and copy your health information.
- You have a right to request that All About Herbs amend your protected health information. Please be advised, however, that All About Herbs is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your protected health information made by All About Herbs.
- You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices

All About Herbs reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, All About Herbs is required by law to comply with this Notice.

All About Herbs is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Dawn Nelson by calling the office at 907-376-8327. If Dawn Nelson is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints

Complaints about your Privacy rights, or how All About Herbs has handled your health information should be directed to All About Herbs by calling the office at 907-376-8327. If All About Herbs' manager is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights 200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, DC 20201
I have read the Privacy Notice and understand my rights contained in the notice.

By way of my signature, I provide All About Herbs with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.
Patients Name print*
Patients Signature*

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Date*

MonthDayYear
Date
©H.J. Ross Company, Inc. 2002, 2003 HIPAA Interactive-All Rights Reserved
Authorization to Use or Disclose Protected Health Information

All About Herbs
Patient Name*
Address*
Date of Birth*

MonthDayYear
Date
As required by the Privacy Regulations, All About Herbs may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

EMI, Electronic Medical Interpretations Patient Health Information authorized to be disclosed: Thermal Images and related health history
I understand I have the right to:

1. Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization.

2. Inspect a copy of Patient Health Information being used or disclosed under federal law.

3. Refuse to sign this authorization.

4. Receive a copy of this authorization.

5. Restrict what is disclosed with this authorization.

I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.
Signature or Patient or Patients Authorized Representative*

Clear
Date*

MonthDayYear
Date
©H.J. Ross Company, Inc. 2002,2003 HIPAA Interactive-All Rights Reserved
REQUEST FOR ALTERNATIVE COMMUNICATIONS
Patient Name*
Address*
Date of Birth*

MonthDayYear
Date
Date of Request

MonthDayYear
Date
As allowed by the Privacy Regulations, I wish for this office to provide the following "Alternative" means of communicating my Protected Health Information:
Mailing Address: If appropriate please contact me at the following address, (*** Emailed reports are FREE, but printed reports do have a FEE***)*
Phone: If appropriate please contact me by telephone at the following number
Fax: If appropriate please contact me by fax at the following number
Email: If appropriate please contact me by email at the following email address: (*** Emailed reports are FREE, but printed reports do have a FEE***)*
I have the following additional requests for confidential communications regarding my Protected Health Information: (Please explain)
I understand that there may be additional costs associated with this request and I agree to reimburse this office for such costs.
Signature*

Clear
Date*

MonthDayYear
Date
©H.J. Ross Company, Inc. 2002, 2003 HIPAA Interactive-All Rights Reserved
Should be Empty:

Symptoms & History

(Female Patient Only)

Disclaimer

All About Herbs

Authorization to Use or Disclose Protected Health Information

REQUEST FOR ALTERNATIVE COMMUNICATIONS