Welcome to Strength & Vitality Wellness Center

Personal Contact Information

      



        

Birth Date:

       

    

Yes, I would like to receive text confirmations of scheduled appointments





Yes, I would like to receive news, updates and offers from Strength & Vitality Wellness Center
(if you checked "yes," please sign up on the next page after you submit this form.)





     
 

How Did You Hear About Us?

Heard from a friend 
Referred by a medical practicioner  
Found you online when searching for  
Found you on social media  

 

Health Information

Your Reasons For Visiting Us (please write 1,2,3,4.. by priority, with 1 being the most important)

Pain

 
Neck Pain Upper Back Pain Arm Pain
Shoulder Pain Lower Back Pain Leg Pain
TMJ Pain Knee Pain Foot/Ankle Pain
Tailbone Pain Elbow Pain Hip/Pelvis Pain
Abdominal Pain Hand Pain Headaches

General Health

 
Anxiety Infertility
Asthma Menapausal Symproms
Cough Sleeping Problems
Allergies Depression



Are your health conditions related to work or auto accident?
Yes    No

If you answered "yes" above, please list the date of the accident


 

Release of Information

In order for you to receive the most comprehensive care from your health care providers, we would like to provide your primary care physician and any other health care providers you indicate with notes of your benefits and progress from acupuncture treatment. If you would like us to do that, please read the below statement and fill out and sign the form.

I understand that my health information is private and that use of my health information must be consistent with the previously signed Notice of Privacy Practices. I further understand that certain disclosures of my health information may only be provided by my written consent. I therefore make the following request and understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.

I, DOB:

authorize Strength & Vitality Wellness to disclose information regarding my health information to:







 

Please list current medications/drugs being taken with dosages



Are you currently taking vitamins, herbs or nutritional supplements? 
If so, please list them below.



Do you have any allergies?  If yes, please list.



Do you use the following and if so, how much?

Cigarettes    
Coffee         
Alcohol        
Soda          
Sugar         
Non-prescription Drugs

Please list any major illnesses, injuries and surgeries with approximate dates


Please list any major scars or body piercings


Number of pregnancies if applicable
Check if currently pregnant



Family Information


Relationship Status:

Name of Spouse/Partner if applicable  



Number of Children



Household Pets

Family History of Serious Illnesses

Cancer     Diabetes     Stroke     Heart Disease


 

Our Mission –

To honor and direct an alliance of these tenets — simplicity, partnership, joy,
clarity, creativity and appreciation — toward the elevation of the human desire to thrive.

 

Our Values –

To educate and empower the individuals that make up families to live in optimal
wellness. We have chosen an approach that is comprehensive and in partnership with other
healthcare professionals.

Our Policies –

Tardiness: Please be courteous and arrive on time for your scheduled appointment. Late arrivals
force us to deduct time from your appointment in order to stay on schedule for other clients throughout
the day. If you believe you will arrive more than 5 minutes past your scheduled time, please call Cara-Michele
at (443) 527-8425 to see if your appointment will need to be rescheduled.
 
Cancellations: We do request a minimum of 24 hours advance notice for any cancellation or rescheduling
of your appointment. This is a consideration to Cara-Michele. Non-emergency short notice or no-notice
cancellations will result in a full office visit charge.
 
Payment of Services: Payment in full is expected at the time of service. Strength & Vitality Wellness Center
accepts payment in the form of cash, check, Visa and MasterCard. If your insurance plan is paying for your
acupuncture services, please read and initial the Insurance Agreement as an indication of your understanding.
 
Nutritional Supplements: Please note that all nutritional supplement sales are final.
 
Returned Checks: A standard fee of $25.00 will be charged for any returned checks.
 
I have read and understand the Strength & Vitality Wellness Center's mission, values and policies.

        
 
 

Consent to Treatment

 
By signing below, I do hereby voluntarily consent to be treated with Acupuncture and/or Whole Food Supplements
by Cara-Michele Nether, M.Ac, L.Ac. I understand that Cara-Michele Nether has earned a Master's Degree from
Tai Sophia Institute for the Healing Arts, a nationally respected institution in the field of acupuncture and herbal
medicine and is completing a training program with the International Foundation for Nutrition and Healing. She has
obtained her license from the Maryland State Board of Acupuncture. I have the right to ask for copies of her license. 
 
I understand that acupuncturists and nutrition counselors practicing in the state of Maryland are not primary care
providers and that regular primary care by a licensed physician is an important choice that is strongly recommended.
 
Acupuncture/Moxibustion:  I understand that acupuncture is performed by the insertion of needles through the skin
or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to
treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. 
I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor
bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. 
I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture
treatment at any time.
 
Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring
from its use. I understand that I may refuse this therapy.
 
Nutrition: I understand that Cara-Michele Nether will be recommending supplementation and nutritional programs based upon
her understanding and experience as a Nutritional Consultant. I also understand that nutritional programs are never intended
as medical advice and do not replace the need for medical treatment and/or advice from my physician. I have been advised
to consult with my physician prior to starting the supplementation and nutritional program.
 
I understand that it is my responsibility as a client to inform my practitioner, Cara-Michele Nether, about all aspects of my
health and, as treatment progresses, to inform her of any changes that occur. If I experience any pain, discomfort, possible
adverse reactions or side effects, it is my responsibility to immediately notify my practitioner. 
 
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.
 
I have carefully read and understand all of the above information and am fully aware of what I am signing.
I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.
 



Please sign below"
   

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