Bookmark and Share
930 Logan Street #101 & 102 Denver, Co 80203 720.284.1374
Licensed Acupuncturist and Practitioner of Chinese Medicine
John S. Aguilar Jr., L.Ac.
Home : My Private Practice : New Patients
Below are the forms and paperwork I use during the initial session. Please feel free to download and review them or even print them out and bring them in completed. Patient Information Form Personal information such as name, address, etc., as well as medical information and history. PDF Word Document Policies Form A short review of standard office and practice policies, such as cancellation fees, right to discontinue treatment, and so on. PDF Word Document Mandatory Disclosure Form Information required by Co state law to be disclosed at the initial treatment session, including information on my license, training, professional degree, and board certifications. PDF Word Document HIPPA Notice of Privacy Practices This packet describes how medical information about you may be used and disclosed and how you can get access to this information. PDF Word Document Acknowledgment of Receipt This is a simple form you sign as indication that you recieved a copy of the above 'Notice of Privacy Practices'. PDF Word Document ***Please note: The following forms are offered, here, for your review only. You will need to sign original copies at the office. Informed Consent This form covers the nature of acupuncture and herbal medicine and talks about potential side effects. PDF Word Document Arbitration Agreement By both of us signing the 'Arbitration Agreement', we agree to use a private, confidential, and expedited arbitration, rather than a lengthy and costly courtroom trial, to settle any potential disputes. (In arbitration, a neutral arbitrator, often a retired judge, decides the case.) This agreement is required by my insurance carrier. Such forms are being used throughout the healthcare industry to keep the cost of insurance down. PDF Word Document *You'll need the Adobe Reader to read the PDFs. You can download the latest version here.
All contents Copyright John Aguilar, Jr. 2008