IVF Intake Form

First Name

Last Name

Address

Unit/Suite #

City

State

Zip Code

Phone

Email Address

Date of Birth (MM/DD/YYYY)

In Case of Emergency Contact

Relationship

Phone

Transfer Day Information
Frozen Embryo Transfer
Fresh Transfer
Not Yet Determined

Which number embryo transfer is this for you?

Date and time of transfer (if known)

How many embryos will be transferred?

Is this a donor cycle?

Fertility Diagnosis, if any

Male Factor, if any

How many stimulation cycles have you done in your life?

Have you ever had issues with your uterine lining during IVF?

Have you ever had acupuncture?
Yes No

Additional Major Diagnoses (including any clotting disorders)?

Herb/Medication allergies and reaction?

To metal?

Medications/Vitamins/Supplements
Please list any medications/vitamins/supplements you are currently taking:

Medications	Dosage	How Long

Anything else you think we need to know:

NOTICE OF PRIVACY PRACTICES - ACKNOWLEDGEMENT
We keep medical records of the health care services we provide you. You may ask to see and copy your records. You may also ask to correct your records. We will not disclose your records unless you give us written consent or unless the law authorizes or compels us to do so. Your de-identified outcomes could be used for research purposes. You may see or get further information about your records by contacting Acupuncture Northwest & Associates.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

Initial:

CONSENT FOR TREATMENT
The "scope of practice" for an acupuncturist in the state of Washington includes but is not limited to the following list of techniques: use of acupuncture needles, use of devices to stimulate acupuncture points, moxibustion, acupressure, cupping, dermal friction, laserpuncture, dietary advice and point injection therapy.

Potential Risks may include but are not limited to the following: pain following treatment in insertion area, minor bruising, infection, needle sickness, broken needle, temporary discoloration of the skin, and aggravation of symptoms existing prior to the treatment.

I request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture and Chinese herbology.

Initial:

TREATMENT and PAYMENT AGREEMENT
I agree to be responsible to Acupuncture Northwest & Associates for charges resulting from services rendered at their established rates. I agree all bills are due in full upon request.

Initial:

Certification: I certify that I have read and understand the authorizations given above and I am the patient, or I am duly authorized by the patient to execute the above and accept its terms.

Patient or legally authorized individual signature

IVF Intake Form

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