David S. Groopman, M.D., FAAMA 4118 E. Parham Road

Richmond, Virginia 23228(804) 755-7800

New Patient Registration

Name___________________________________________________ Sex (circle one) Male Female

Street Address ________________________________________________________________________________

City, State, Zip________________________________ Home Phone ( )_____________________________

Date of Birth ____/_____/_____ Age ______ Marital Status (circle one) Single Married Divorced Widowed Separated

Employer _________________________________ Occupation ______________________________________

Work Phone ( ) _____________________ Referred By __________________________________________

Emergency Contact (Name and Phone #) _____________________________________________________

For Women Only: Are You Pregnant? Yes No

For All Patients:

Have you had acupuncture before? Yes No Chinese herbal medicine? Yes No

What is the reason for today’s visit? ____________________________________________________________

How long have you had this condition? ____________ Initial cause? ______________________________

Does it bother your: Sleep Work Other (What?) __________________ Is it getting worse? Yes No

What makes it better? _________________________ What makes it worse? __________________________

Are you under the care of a physician now? Yes No If yes, for what condition? _______________

Who is your physician? _____________________________ Physician phone # ________________________

Rev. 09/01/08

David S. Groopman, M.D., FAAMA

Acupuncture Informed Consent to Treat

I, ____________________________________________________, being __________ years of age and residing at _____________________________________________________, do hereby voluntarily consent to be treated with acupuncture administered by David S. Groopman, M.D.

Acupuncture is performed by the insertion of very thin needles through the skin, and/or by application of heat on or near the surface of the body, and/or by suction cups applied to the skin. Once inserted, the needles may be stimulated manually or electrically, and/or may have certain Chinese medicine herbs burned on or near them.

I have been informed and understand that acupuncture is a generally safe method of treatment, but certain adverse side effects, while infrequent, may result. These could include but are not limited to local bruising, minor bleeding, numbness or tingling near the needling sites, temporary pain or discomfort and dizziness, nausea or fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax), and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that there is a risk of burning/scarring from moxibustion (heating of needles with herbs) and/or cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

I have been informed and understand that Dr. Groopman does not practice primary care medicine and does not offer any services other than acupuncture and treatment modalities directly relating to the practice of acupuncture.

I have been informed and understand that Dr. Groopman does not diagnose medical conditions.

I have been informed and understand that I will need to consult with another healthcare provider if I seek a diagnosis for my condition(s) or if I seek services other than acupuncture.

I have been given no guarantees regarding the use and/or effectiveness of acupuncture and know that I am free to stop treatment any time.

By voluntarily signing below, I show that I have carefully read and understand the above consent to treatment, have been advised about the risks of acupuncture and related procedures. I intend this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.

Signature of Patient or Guardian: _______________________________________ Date: _______________________

Rev. 09/10/2009David S. Groopman, M.D., FAAMA

Fees and Payment Policy

Dr. Groopman does not participate with any insurance carrier. Our office does not file insurance claims.

WE DO NOT ACCEPT DEBIT/CREDIT CARDS. WE DO ACCEPT CASH AND CHECKS.PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE.

New Patient - Initial VisitIncludes Chinese Medicine Assessment and Acupuncture Treatment $ 250.00

Established Patient – Acupuncture Treatment $ 145.00

Scar Deactivation / Injection $ 75.00

Broken Appointment / Late Cancellation Policy:

You may be charged the full visit amount for broken appointments or cancellations without 24 hours advance notice.

I understand that I am responsible for full payment of all services at the time they are rendered. I have read and understand the broken appointment/late cancellation policy.

Signature: _________________________________________ Date: ____________________________________

ATTENTION MEDICARE BENEFICIARIES

MEDICARE DOES NOT COVER ACUPUNCTURE. DR. GROOPMAN HAS OPTED OUT OF THE MEDICARE PROGRAM. WHEN A PHYSICIAN OPTS OUT OF MEDICARE, MEDICARE REQUIRES A PRIVATE CONTRACT BE SIGNED BY BOTH PHYSICIAN AND PATIENT PRIOR TO SERVICES BEING RENDERED. CARFULLY READ, SIGN AND DATE THE ATTACHED PRIVATE CONTRACT. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS.

Revised 06/05/2013

COMPLETE ONLY IF YOU ARE A MEDICARE BENEFICIARY. OTHERWISE LEAVE BLANK.

MEDICARE BENEFICIARY PRIVATE CONTRACT FOR MEDICAL SERVICES

Dr. Groopman has chosen to opt out of the Medicare program. When a physician opts out of Medicare, Medicare requires the following private contract be signed by both physician and patient prior to services being rendered. Opt out status is effective for a period of 2 years and can be renewed/continued. A new contract must be signed for each opt out period.

Please read carefully, sign and date. ---------------------------------------------------------------------------------------------------------------------------------------------------This contract is entered into by and between: David S. Groopman, M.D. (physician) Patient Name: ___________________________________ 4118 E. Parham Road and Address: ________________________________________Richmond, Virginia 23228 City,State,Zip: ___________________________________

I understand that David S. Groopman, M.D. has opted out of the Medicare program. The current opt out period begins April 1, 2014 and expires on March 31, 2016. I understand that Dr. Groopman has the option to renew the opt out status every 2 years. I understand I will be required to sign a private contract each time Dr. Groopman renews his opt out status. ---------------------------------------------------------------------------------------------------------------------------------------------------

Physician Obligations

The physician acknowledges:

1. He is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act.

2. This contract shall not be entered into with the beneficiary or the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. (405.440).

3. He must retain this contract with original signatures of both parties to this contract for the duration of the opt-out period, and it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request.

4. That he must enter into a contract for each opt-out period.

The physician shall provide a copy of this contract to the beneficiary, or to his legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

Patient/Beneficiary Obligations

The beneficiary or his or her legal representative:

1. Agrees not to submit a claim, nor ask the physician to submit a claim, for any items or services furnished by physician.

2. Accepts full responsibility for payment of the physician’s charge for all services furnished by the physician. 3. Understands that no payment will be provided by Medicare for items or services furnished by the physician that

would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

4. Understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.

5. Has entered into this contract with the knowledge that he or she has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted-out.

6. Understands that Medigap plans do not, and other supplemental plans may elect not to, make payment for items and services not paid for by Medicare.

7. Acknowledges that this agreement is not being entered into with the physician at a time when the patient/beneficiary requires emergency care services or urgent care services.

8. Acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before services have been rendered to the beneficiary under the terms of this contract.

The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.

Physician Signature: ____________________________ Patient Signature: ___________________________________Printed: David S. Groopman, M.D. Date: ____________________________ Date: ___________________________________

Medical History Questionnaire

Family Medical History

___ Allergies (list): ________________________________________________________________________ Arteriosclerosis___ Asthma___ Alcoholism___ Cancer (list): _________________________________________________________________________ Diabetes___ Heart Disease___ High Blood Pressure___ Seizures___ Stroke

Your Past Medical HistoryCheck any of the following conditions you currently have or have had in the past.

___ AIDs/HIV ___ Mumps___ Alcoholism ___ Pacemaker___ Allergies ___ Pleurisy___ Appendicitis ___ Pneumonia___ Arteriosclerosis ___ Polio___ Asthma ___ Rheumatic Fever___ Birth Trauma (your birth) ___ Scarlet Fever___ Cancer ___ Seizures___ Chicken Pox ___ Stroke___ Diabetes ___ Surgery (list): ______________________________________________ Emphysema ___ Thyroid Disorders___ Epilepsy ___ Major Trauma (list car accidents, falls, etc. _______________________ Goiter __________________________________________________________ Gout ___ Tuberculosis___ Heart Disease ___ Typhoid Fever___ Hepatitis ___ Ulcers___ Herpes ___ Venereal Disease___ High Blood Pressure ___ Whooping Cough___ Measles ___ Other (list): ________________________________________________ Multiple Sclerosis _______________________________________________________

Your Diet

Appetite (circle one) High Low Average Daily Menu

___ Coffee (cups per day) Morning _______________________________________ Soft Drinks (per day) Snack _______________________________________ Artificial Sweetener Noon _______________________________________ Sugar Snack _______________________________________ Salty Food Evening ____________________________________

___ Water (per day) Snack ____________________________________

Medications/Vitamins/Supplements

List all taken within the last 2 months: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your Lifestyle

___ Alcohol (per week) _______________________ Tobacco (per week) ______________________ Marijuana___ Drugs___ Stress___ Occupational Hazards___ Regular Exercise (list type and frequency) _______________________________________________

_________________________________________________________________________________

General Symptoms

___ Poor appetite ___ Cold hands or feet___ Heavy appetite ___ Poor circulation___ Strongly like cold drinks ___ Shortness of breath___ Strongly like hot drinks ___ Fever___ Recent weight loss/gain ___ Chills___ Poor sleep ___ Night sweats___ Heavy sleep ___ Sweat easily___ Dream disturbed sleep ___ Muscle cramps___ Fatigue ___ Vertigo or dizziness___ Lack of strength ___ Bleed or bruise easily___ Bodily heaviness ___ Peculiar taste (describe): _________________________________

Head, Eyes, Ears, Nose, Throat

___ Glasses ___ Excessive phlegm (color): ____________________________________ Eye strain ___ Recurrent sore throat___ Eye pain ___ Swollen glands___ Red eyes ___ Lumps in throat___ Itchy eyes ___ Enlarged thyroid___ Spots in eyes ___ Nose bleeds___ Poor vision ___ Ringing in ears___ Blurred vision ___ Poor hearing___ Night blindness ___ Earaches___ Glaucoma ___ Headaches___ Cataracts ___ Dry mouth___ Teeth problems ___ Excessive saliva___ Grinding teeth ___ Sinus problems___ TMJ ___ Migraines___ Facial pain ___ Concussion___ Gum problems ___ Other head/neck problems _________________________________

___ Sores on lips/tongue _______________________________________________________

Respiratory

___ Difficulty breathing when lying down___ Shortness of breath___ Tight chest___ Asthma/wheezing___ Cough Wet or Dry? ________ Thick or Thin? ______________ Color of phlegm? ________________ Coughing Blood___ Pneumonia

Cardiovascular

___ High blood pressure ___ Difficulty breathing___ Blood clots ___ Tachycardia___ Low blood pressure ___ Heart palpitations___ Fainting ___ Phlebitis___ Chest pain ___ Irregular heartbeat

Gastrointestinal

___ Nausea ___ Intestinal pain/cramping___ Vomiting ___ Itchy anus___ Acid regurgitation ___ Burning anus___ Gas ___ Rectal pain___ Hiccup ___ Hemorrhoid___ Bloating ___ Anal fissures___ Bad breath___ Diarrhea Bowel movements: Frequency ______________________________ Constipation Color ______________________________ Laxative use Texture/form ____________________________ Black stools Odor ______________________________ Bloody stools___ Mucous in stools

Musculoskeletal

___ Neck/shoulder pain ___ Rib pain___ Muscle pain ___ Limited range of motion___ Upper back pain ___ Limited use ___ Lower back pain ___ Other _____________________________________________________ Joint pain

Skin and Hair

___ Rashes ___ Itching___ Hives ___ Hair loss___ Eczema ___ Change in hair/skin texture___ Psoriasis ___ Fungal infections

___ Acne ___ Other hair/skin problems _____________________________________ Dandruff

Neuropsychological

___ Seizures ___ Irritability___ Numbness ___ Easily stressed___ Tics ___ Abuse survivor___ Poor memory ___ Considered/attempted suicide___ Depression ___ Seeing a therapist___ Anxiety ___ Other _______________________________________________

Genito-urinary

___ Pain on urination ___ Wake to urinate___ Frequent urination ___ Increased libido___ Urgent urination ___ Decreased libido___ Blood in urine ___ Kidney stone___ Unable to hold urine ___ Impotence___ Incomplete urination ___ Premature ejaculation___ Venereal disease ___ Nocturnal emission___ Bedwetting

Gynecology

Age menses began _______ Length of cycle (day 1 to day 1) _______ Duration of flow _________

___ Irregular periods___ Painful periods___ PMS___ Vaginal discharge (color) _______________ Vaginal sores___ Vaginal odor___ Clots___ Breast lumps___ Breast Implants

Number of pregnancies _____ Number of Live Births _____ Number of premature births ______

Age at Menopause _________ Date of last PAP _________ Start date of last period __________

Other:______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

David S. Groopman, M.D., FAAMA4118 E. Parham Road

Richmond, Virginia 23228

Medical Information Disclosure Authorization

I authorize David S. Groopman, M.D. to discuss and disclose any/all information regarding my medical condition(s) and medical care to the following person(s):

Name: ________________________________________ Relationship to Patient: _________________

Name: ________________________________________ Relationship to Patient: _________________

Name: ________________________________________ Relationship to Patient: _________________

Patient Name (PLEASE PRINT):_________________________________________

Signature of Patient/Guardian: ________________________________________ Date: __________________

HIPAA Privacy Practice Written Acknowledgement

Notice of Privacy Practices Written Acknowledgement Form

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change in accordance with Federal regulations.A current paper copy will be provided at your request.

I acknowledge I have been provided a copy of the Notice of Privacy Practices for David S. Groopman, M.D., FAAMA.

Patient Name (PLEASE PRINT):__________________________________________

Signature of Patient/Guardian: _________________________________________ Date: __________________