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Please Note:

Filling out this form is not a guarantee of acceptance as a patient. Dr. Tillotson will review the information to ensure that your particular case is aligned with the expertise of the Clinic.

Email *

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code *

Mobile Phone *

Additional Phone

Patient Date of Birth *

I am interested in (check one or both boxes):

Interested in: *

Herbal medicine
Acupuncture

WHAT WE DO AND DO NOT DO AT CHRYSALIS

Check the box below if you agree that you understand the below statements about what we do and do not do at Chrysalis *

I FULLY UNDERSTAND that Chrysalis provides only nutritional, herbal, lifestyle and acupuncture support for improving health, that natural medicines support health but do not treat disease, that I am encouraged by the Chrysalis staff to rely on my regular doctors for all ordinary medical care and for any emergency care. I understand the general time and costs involved, I have read the refund policy and I agree I am responsible for and agree to pay for any and all costs incurred at time of in person, phone or video consultations, and also for any orders I place any time with Chrysalis, and all for visits/orders I put on my credit card(s). I also understand that I may be charged if I do not provide a notice of cancellation to Chrysalis at least 24 hours (business days) in advance of my scheduled appointment.

PRIVACY RULES

Check the box below if you agree that you understand the below statements about privacy rules *

I FULLY UNDERSTAND that Chrysalis staff will not release or discuss my records or medical condition without my written consent, except as needed to conduct normal office business (check-out etc), with our staff, and with my treating physicians. I may give verbal consent for family/friends accompanying me.

ACUPUNCTURE INFORMED CONSENT TO TREAT

Check the box below if you agree that you understand the below statements about informed consent *

I CONFIRM that I have read, or have had read to me, the Acupuncture Informed Consent to Treat in the link below, have been told about the risks and benefits of acupuncture and other procedures, herbal medicine, nutrient and vitamin therapy, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Informed Consent

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ACUPUNCTURE INFORMED CONSENT TO TREAT

I understand that I am the decision maker for my health care. Part of this office's role is to provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me {or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with, or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to: bruising; numbness or tingling near the needling sites that may last a few days; and dizziness or fainting. Bums and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. Some possible side effects of taking herbs are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; and tingling of the tongue.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.

I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter). I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

I understand that there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

By voluntarily clicking the checkbox, I confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date *

I am: *

Is the patient under the age of 18? *

INSURANCE: Chrysalis does not currently accept any insurance, and, specifically, we do not accept Medicare or Medicaid, nor are we Medicare or Medicaid providers. However, patients may use HSA and MSA credit cards to pay for goods and services, because we are state licensed medical providers.

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New Patient Intake Form

Please Note:

Please list health/nutrition issues would you like to discuss on your first visit below and the approximate dates they started, separated by a comma:

List all prescription medications you are currently taking, and what for, separated by a comma:

List all vitamins and nutritional supplements you are currently taking, and what for:

List any symptoms that you may be experiencing in these general areas:

I am interested in (check one or both boxes):

WHAT WE DO AND DO NOT DO AT CHRYSALIS

PRIVACY RULES

ACUPUNCTURE INFORMED CONSENT TO TREAT

ACUPUNCTURE INFORMED CONSENT TO TREAT