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:_____________