MobileOsteopathy,P.A.
ComplementaryandAlternativeMedicine(CAM)Informed
ConsentForm
Definitions:CAMreferstoabroadrangeofhealingphilosophies,approachesandtherapiesthatmainstream
Western(conventional)medicinedoesnotcommonlyuse,accept,study,understand,ormake
available.AfewofthemanyCAMpracticesincludeacupuncture,herbs,homeopathy,meditation,
energymedicine,therapeuticmassage,andtraditionalOrientalmedicinetopromotewell-beingor
treathealthconditions.CAMtherapiesmaybeusedalone,asanalternativetoconventional
therapies,orinadditiontoconventional,mainstreamtherapies,inwhatisreferredtoas
complementaryoranintegrativeapproach.
Conventionalmedicalpracticesrefertothosemedicalinterventionsthataretaughtextensively
atU.S.medicalschools,generallyprovidedatU.S.hospitals,ormeetrequirementsofthegenerally
acceptedstandardofcare.
Bysigningbelow,Iagreetothefollowing:
• IunderstandthatMatthewBarker,DOcombinesconventionalmedicinewithavarietyof
CAMtherapiesinanintegrativeapproachtomedicalpractice.Dr.Barker’sgoalisto
optimizepatienthealthwhileminimizingrisksassociatedwithtreatmentornon-treatment
ofmedicalconditions.
• Afterassessingmycondition,Dr.Barkerhastoldmeaboutmyconditionandhas
recommendedintegratedmedicaltreatments.Hehasdiscussedwithmethegoals,riskand
benefits,possibleinterferencewithconventionaltreatments,andthetherapeuticbasisof
anyrecommendedtreatment.Refusaltochooseanalternativetreatmentwillnotaffectmy
righttofuturecareortreatment.
• Dr.Barkermayrefermetoanotherhealthcareproviderwhopracticesconventional
medicine,CAM,oracombinationofthetwo.IunderstandthatDr.Barkerisnot
MobileOsteopathy,P.A.responsibleforanyoutcomethatmayresultfromatreatmentorrecommendation
providedbyanotherhealthcareprovider.
• IunderstandthatDr.Barkerisnotmyprimarycareprovider.Iunderstandandacceptfull
responsibilitytocommunicatemytreatmentchoiceswithmyprimarycareandother
healthproviders.
• Iunderstandthatemergencycareandhospitaltreatmentarenotincludedinthis
agreement.
• IunderstandthatImaypurchasenutritionalsupplements,medicalsupplies,andother
items,whichDr.Barkermayreceivefinancialbenefit.
• Nowarrantyorguaranteehasbeenmadetomeregardingtheoutcomeofthecareand
treatmentsImayreceive.Irealizethatrisksandhazardspersistwithconventional
medicaltreatment,alternativecare,ornotreatmentatall.Ihavehadanadequate
opportunitytoinquireaboutmycondition,conventionaltreatment,alternativetreatment,
risksoftreatmentandnon-treatment,procedurestobeused,andtherisksandbenefits
involved,andIbelieveIhavesufficientinformationtogivethisinformedconsent.Icertify
thatthisformhasbeenfullyexplainedtome;IhavereaditorhavehaditreadtomeandI
understanditscontents.
PatientName(print):___________________________________
PatientorLegalGuardian(signature):___________________________________Date:___________
Doctor(signature):___________________________________Date:_____________
fII
Mobile OsteoPathY, P.A.
Date:
NeW Patient RegistfatiOn FOfm Please Print and Fillout all Forms
Emergency ContactFirst- Last- Relationship
Home Cell
lnsurance Information Please fill out information for Person on Policy
lnsurance Company.
Group # Policy #
Name of Policy Holder
First Ml_ Last.
Sex:D.O.B
Patient Name:i rst Ml- Last
DOB:
treet
rpt #_
)ity_
Sex:
zip, State
Home
-
Cell
mail Marital Status- Race
mployer. Occupation
Referred By:
Page 1 of 4 Copyright 2017. Mobile Osteopathy, P.A., All rights reserved.
rcI
Mobile OsteoPathY, P.A.
Medical Historv
Allergic Rhin itis/Seasona I Allergies
High Blood Pressure
mia/MurmurHeart Attack/AnginaAsthmaCOPD(lung disease)
Reflux (GERD)
HepatitisKidney Disease
ArthritisEnlarged Prostate
HIV/AIDS
Su rgical HistorvType of Surgery Year
AllergiesNarne of MedicationlFood Reaction
Check all that Apply
ke
High Cholesterolroid disease
DiabetesSkin Cancer
Cancer (typ")
emales onNumberofpregnancieS-DateofLastMenstrualPeriodNumber of live births - Flow:-Light
- Moderate
- Heavy
Number of miscarriages_ Length of Flow
Method of birth control_ Frequency of Cycle
Age of onset of menses_
Page2of 4 Copyright 2OL7. Mobile Osteopathy,P.A., All rights reserved.
sl.t
Mobile Osteopathy, P.A.
CUffent SymptOtTlS (Check allthat apply within the last two weeks)
GeneralnF"r",I lcnitttI lr"tieuel-lnecent Weight Change
Eyes
nD".r"rsed Vision
l-loouUte or Blurred Vision
I lrv" discharse
I-lrye eain
ENT
PulmWheezing
Dry Cough
Wet Cough
Chronic Cough
Shortness of Breath on Excertion
Endo
Decreased HearingSnoring/Mo uth Breath ing
Ringing/Buzzing in Ea rs
Alle rgies/Hay Feve r/Run ny Nose
Sinus ProblemsNose Bleeds
Sore ThroatCardiovascular
Excessive ThirstExcessive UrinationExcessive HungerHeat or cold intoleranceDry Skin
Brittle Hair/Nails
ConvulsionsfSeizuresTremorsMuscle WeaknessNumbness/TinglingHeadaches
Dizzines
Pain Radiatin Down Arm/LeE;
Joint pain
Scoliosis
Joint SwellingDecreased Range of MotionMuscle Pain
Neck Pain
Back Pain
HEME
l-.lgruise easily
l_laleedingNeuro
Shortness of Breath lying Flat
Chest Pain
PalpitationsSwollen Ankles
Fainting Spells
Leg Pain When Walking
Loss of AppetiteDifficulty SwallowingHeartburnNausea
VomitingAbdominal Pain
Change in Bowel Habits
DiarrheaConstipationBlack or Tarry StoolsRed Blood in Stools
Hemerrhoids
MS
Derm
Rashes
Hives
Unusual MolesSkin Lesions
Itching
GI
Page 3 of 4 Copyright 2017. Mobile Osteopathy, P.A., All rights reserved.
& Mobile Osteopathy, P.A.
current symptoffls (check allthat apply within the last two weeks)
PSYCH/EMOTIONAL Genitourinary
Other Current Symptoms
Cu rrent Medications/Vitamins/Su pplements
Name Dose/Frequency
Siginature of Patient or Legal Guardian: Date:
Name of Legal Guardian or Patient {Please Print):
Page 4 of 4 Copyright 2OL7. Mobile osteopathy, P.A., All rights reserved.
Pain on UrinationBlood in urineDischarge from penis or vagina
Pain During I ntercourselncreased Urinary Frequency
Urinary UrgencyBladder lncontinenceUrinary Retention
f Mobile Osteopathy, P.A.
Financial Policies
Our goal is to get you back to your optimal health. We are not contracted withany private insurance companies. What that means for all of our patients is that paymentis required at the time services are rendered. All patients will be provided with a Superbill(a document indicating the services rendered and showing funds collected) and it will beyour responsibility to submit it to your insurance company for possible reimbursement.Each insurance company differs in what percentage they will reimburse you for out ofnetwork providers and you would need to contact them directly to obtain thatinformation. Mobile Osteopathy, P.A. does not guarantee that your insurance companywill reimburse you. Sometimes, your insurance company will request the note from theoffice visit to verify services prior to reimbursing you. If this does occur, we will make
every effort to supply your insurance company with any requested documents. If yourinsurance company mistakenly sends your reimbursement check to us, we wiltr return it toyour insurance company and ask them to reimburse you directly. Please be aware thatthere will be a $25 charge for any checks that you write to Mobile Osteopathy P A whichare returned for insufficient funds.
Cancellation Policy
We believe that we provide a unique service by coming to your home to providepersonal medical care. We know that plans change and emergencies happen. If you doneed to cancel or reschedule your appointment, we ask that you notify us at least 24 hoursprior to your appointment time.
By signing below, I acknow-ledge that I have read and understand the above policies:
Name of Pati ent/Gu ardian'. Date:
Si gnature of Pati ent/Guardi an
Copyright 2017. Mobile Osteopathy, P.A., All rights reserved.
f Mohile osteopathy, P.A.Patient Consent Form for Use and Disclosure
of Protected Health Information (PIII)
(The Notice of Privacy Practices provided by Mobile Osteopathy, P.A. describes such uses
and disclosures more completely.)
By initialing below, I give consent to Mobile Osteopathy, P.A. to disclose and use my protected
health information (PHI) for treatment, payment and health care operations (HCO).Initials:
By initialing below, Mobile Osteopathy, P.4. may contact me at the numbers I have provided
and can leave messages via voice mail regarding any information that assists MobileOsteopathy, P.4. tL carrytng out HCO, such as appointment dates and times, insuranceinformation and all calls or communications in regards to my clinical care, including lab testresults, imaging results, etc.
Initials:
By initialing below, Mobile Osteopathy, P.A. has my permission to text me on the cell phonenumber I have provided in regards to any information needed to assist in carrying out HCO, suchas appointment times and dates.
Initials:
By initialing below, Mobile Osteopathy, P.A. may e-mail me at the address provided by me any
items that assist the practice in carrying out HCO, such as appointment reminder cards andpatient statements. I have the right to request that Nlobile Osteopathy, P.A. restrict how it uses
or discloses my PHI to carry out HCO. The practice is not required to agree to my requestedrestrictions, but if it does, it is bound by this agreement.Initials:
By initialing below, I understand that I have the right to request that Mobile Osteopathy, P.A.restrict how it uses or discloses my PHI to carry out HCO. Mobile Osteopathy, P.A. is notrequired to agree to my requested restrictions, but if it does, it is bound by this agreement.Initials:
By initialing below, Mobile Osteopathy, P.A. can send mail to my home address or otherlocations I have provided in regards to information needed to assist Mobile Osteopathy, P.A. incarrying out HCO. I understand that mail sent to my home containing PHI will be marked"Personal and Confi denti al,"Initials:
Copyright 2017. Mobile Osteopathy, P.A., All rights reserved.
By initialing below, I understand that I have the right to review the Notice of Privacy Practicesprior to signing this consent. I understand that I may find the most updated copy of the policy on
www.mobile-osteopath)z.com or I may request a copy. Mobile Osteopathyo P.4. reserves theright to revise its Notice of Privacy Practices at any time. If I wish to obtain a revised Notice ofPrivacy Practices a written request must be sent to Matthew Barker, DO at PO Box 331, Haslet,TX760s2.Initials:
My signature below indicates that I allow Mobile Osteopathy, P.A. to use and disclose my PHIto carry out HCO.
I understand that I can revoke my consent in writing as long as Mobile Osteopathy, P.A. has notalready made disclosures in reliance upon my prior consent. Mobile Osteopathy, P.A. candecline to provide treatment to me if I chose to revoke or decline to provide my signature below.
Signature of Patient or Legal Guardian
Print Patient's Name Date
Print Name of Patient or Legal Guardian, if applicable
Copyright 20t7. Mobile Osteopathy, p.A., All rights reserved.
MobileOsteopathy,P.A.
OMTConsentFormBysigningbelow,Iagreetothefollowing:
• Iunderstandthatosteopathicmanipulativetreatment(OMT)isconsideredamedicalprocedureandtherisksandbenefitshavebeenexplainedtome.
• Iunderstandthatatthebeginningofeachvisit,mydoctorwillevaluatemefortheindicationsandcontraindicationsforOMTandthatthereisnoguaranteethatOMTwillbeperformed.IfOMTisnotperformed,Iamstillresponsiblefortheencounterportionofthevisit.
• IunderstandthatImaybeevaluatedandtreatedinallareasofthebodyasmedicallyindicatedandthatImayverballyrefuseanyportionoftheexamortreatmentatanytime.
• IunderstandthatifIwouldlikeachaperonepresentduringmyappointment,thatIwouldneedtoprovideonemyself.
• Iunderstandthatanypatientundertheageof18willrequireaparentorguardiantobepresentduringtheentireappointment.
PatientName(print):___________________________________PatientorLegalGuardian(signature):___________________________________Date:___________Doctor(signature):___________________________________Date:_____________