Iris Netzer, L.Ac. | Kim Schwartz-Finkelstein, L.Ac | Marcy Julius L.Ac. | Sarah Heslip, L.Ac.

201 East 56th St. NY, NY 10022

Phone: 212-991-8680

Email: info@aprpc.com

Patient Intake Form

First Name: Last Name:

Email: Phone:

Birth Date:

Address: City: State:

Zip: Country:

CVV:

Health Insurance Information

Insurance Provider:

Name Of Primary Insured:

Insured Date Of Birth:

Insurance ID:

__________________________________________________________________________________

Please note: The information you are asked to provide is pertinent within the scope of Chinese Medicine. If you have any questions regarding any content on this intake form, feel free to ask or contact us and one of us will be happy to explain. Acupuncture Remedies respects your privacy and complies with HIPAA patient information requirements.

Your Health History

Have you ever had acupuncture?

If yes, when?

For what condition?

Height:

Weight:

Are you currently under the care of a physician?

If so, who?

For what condition(s)?

Main reason(s) for seeking acupuncture:

How long have you experienced symptoms?

Your condition is improved by:

Your condition is aggravated by:

List all current medications, prescribed or over the counter:

List all current vitamins, herbs and other supplements:

Significant illnesses (please check all that apply)

Cancer	Multiple Sclerosis	*HIV / Aids Yes No	Obesity
Tuberculosis	Chronic Fatigue	Pneumonia	Depression
Shingles	Heart Disease	Thyroid	Rheumatic Fever
Diabetes	Stroke	Asthma	High Blood Pressure
Hepatitis	Seizures	Stomach Ulcers	Sexually Transmitted Diseases

Other:

Please list any surgeries you’ve had including dates:

Please list any allergies:

Please list any major emotional or physical traumas you’ve experienced:

Lifestyle (please check all that apply, and note frequency of use)

Tobacco	Recreational Drugs
Alcohol	Caffinated Beverages

Do you exercise?

Please list types of activity and frequency:

Dietary preferences

Vegetarian	Fish / seafood	Hot drinks	Spicy / hot
Vegan	Red meat	Ice chewing	Eggs
Raw foods diet	Artificial sweeteners	Extreme thirst	Chicken
Low fat diet	Fast food/ burgers/fries	Thirst with no desire to drink	Sweet
High protein/low carb	Cold drinks	Dairy /milk /cheese	Sour

General Symptoms

Fatigue	Dizziness / vertigo
Sweat without exertion	Bleed / bruise easily
Night sweats	Low immunity
Fever / chills	Other:

Digestion

Extreme appetite	Acid regurgitation
No appetite	Dieting
Bloating	Tired after eating
Gas	Heartburn/ulcers
Vomiting	Nausea
Bulimia	Irritability or low energy between meals
Cravings	Other:

How many meals per day?

How many snacks per day?

Intestinal

Diarrhea	Gout
Constipation	Anal itching / burning
Hemorrhoids	Incomplete evacuation
Mucous in stool	Nausea
Anal fissures	Gallstones
Intestinal pain/cramping	Laxative use
IBS	Bloody stool
Colitis	Other:

Sleep

Fall asleep easily	Wake up not feeling rested	Wake frequently to urinate
Vivid or lucid dreams	Wake at specific times	Nightmares or frightening dreams
Lie in bed with eyes open	Wake repeatedly	Need drugs or supplements to fall asleep

Head, Eyes, Ears, Nose and Throat

Dry eyes	Blurred vision	Cataracts	Earaches
Bleeding gums	Sores on tongue or mouth	Dry mouth	Tinnitus / ringing
Sore throat	Swollen glands	Excess saliva	Deafness
Spots / Flowery vision	Poor vision	Sinus problems	Macular degeneration
TMJ	Eye strain	Nosebleed	Post-nasal drip
Headaches	Night blindness	Diï¬€iculty swallowing	Other

Cardiovascular/respiratory

Heart palpitations	Dificult inhalation	Shortness of breath	Varicose veins
Chest pain	Dificult exhalation	Productive cough	Blood clots
Heart valve abnormality	Dificulty breathing	High cholesterol	Swollen ankles

Dry cough	Productive cough (color or phlegm?)
Wheezing	Cold hands/feet
Chest tightness	Other:

Skin and Hair

Dry skin	Cold hands/feet	Ridged nails
Rashes / hives	Pimples / acne	Hair loss
Eczema	Fungal infections	Dandruff
Psoriasis	Brittle nails	Other:

Musculoskeletal

Spinal pain	Arthritis
Limited range of motion	Vertebral disc degeneration
Numbness	Osteoporosis
Joint pain	Carpal tunnel
Tendonitis	Other
Swelling	If Other Please Explain:

Neuropsychological

Anxiety	Tics	Easily stressed
Seasonal mood disorder	Tremors	Poor memory
Recent divorce	Currently in therapy	Death of someone close
Irritability	Financial setback	Job stress
Insomnia	Depression	Other:

Emotional stress scale

1 2 3 4 5 6 7 8 9 10

(no stress) (moderate) (extremely stressed)

Rate your stress level regarding:

Work
Health
Love
Money
Family
The future
General

Genito-urinary

Frequent urination	Blood in urine
Wake frequently to urinate	Bedwetting
Loss of urine when laughing or sneezing	Decreased libido/sexual desire
Kidney stones	Impotency
Incomplete urination/retention	Infertility
Dribbling	Other
Burning urination	If Other Please Explain:

Men only

Erectile dysfunction

Prostate problems

Other

___________________________________________________________________________________

Women only

Age menses began:

Age menses ended (if applicable):

Date of last OB/GYN exam:

Hysterectomy? Partial Full Hormone replacement therapy

Headaches before menstrual cycle during cycle after cycle

Abortion(s)	Breast cancer	Vaginal discharge
Miscarriage	Ovarian cysts	Vaginal odor
Live births	Fibroids	Vaginal sores
Birth control pills	Candida/yeast	Herpes

STD history (chlamydia, PID, etc)	Acne associated with period	Irregular cycle
Fibrocystic breast	Constipation or diarrhea associated with period	No period/skipped cycles
Pain at ovulation	Emotional irritability or depression associated with period	Human Papilloma Virus positive
Cramps/low back pain	Bleeding outside of regular menstrual cycle

Period lasts days. Usual number of days between periods

Menstrual Flow

Clotting

Brownish

Normal red

Flooding and tricking

Watery, thin and bright red

Stop and start flow

If you have been evaluated for infertility, what was your diagnosis?

___________________________________________________________________________________

Acupuncture is NOT a substitute for conventional medical diagnosis and treatment. Techniques commonly employed in the application of acupuncture:

Acupuncture needling – treatment will consist of the insertion of sterile disposable needles at specific sites on the body. Stimulation of said needles may be by manipulation, electrical stimulation or the application of warming substances (moxa) on the needle itself.
Auxiliary / Associated therapies – massage, assisted stretching, topical application of liniments.

There is no guarantee that acupuncture will help any condition. Certain medications and social habits may decrease the beneficial eï¬€ects of acupuncture. These include the use and abuse of alcohol, tobacco, steroids, painkillers, narcotics, stimulants, antidepressants, psychopharmaceuticals and illegal drugs.

I, , certify that I have read and understood the statements above. I also certify that I have informed my acupuncturist of all known physical, mental and medical conditions and medications, and I will keep her updated on any changes.

Payment and Refund Policy

Payments can be made by Visa, Master Card, American Express, Discover, check or cash. Make checks payable to Acupuncture Remedies, P.C.. Full payment is expected at the time the services are rendered. There are no refunds for unused package sessions. All sales are final.

Explanation of Insurance Coverage

Many insurance policies do cover acupuncture care but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this oïffice. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner.

If you must cancel your appointment, please notify us as soon as possible. In order to uphold our high standard of care, we must adhere to a standard 24-hour cancellation policy. Please note: existing patients will be docked one session or charged $100 for less than 24-hours cancellation and/or a no-show.

One's insurance cannot or will not be charged in lieu of a missed appointment. Patient will assume full responsibility for the missed appointment or late cancellation.

I, , certify that I have read and understood the statements above and agree to abide by them.

___________________________________________________________________________________

Notice of Privacy Practices

This Notice together with the Practices Regarding Disclosure of Health Information, describe how health information about you may be used and disclosed. They also describe how you can gain access to your health information. Please review this information carefully.

Understanding Your Health Record

A record is made each time you visit the office for treatment. This record includes symptoms, clinician observations, diagnosis and treatment. The record may also contain other pertinent information provided by you or another of your health care practitioners with whom we may have spoken.

Your Health Information Rights

This office owns your health record, however, the content is always available to you for your review. You have the right to request a review of your file and to obtain copies of documents contained in your file. You also have the right to request that amendments be made to you record. In addition, you may request that the use of your information be restricted from certain uses and disclosures and to request a list of individuals of entities to whom your information has been disclosed. You may revoke any authorizations you have given regarding disclosure of your health information at any time. This revocation must be provided to this office in writing.

Our Responsibilities

We are required to maintain the privacy of your health information and to provide you with a copy of the Notice of our privacy practices. We will follow the terms of this Notice and advise you if we are unable to comply with a request you may make regarding the use of your health information. We reserve the right to amend our privacypolicies and we use our best efforts to notify you of any such amendments. Other than for reasons stated in this notice, we will not use or disclose your health information without your consent.

I, , have received a copy of the Notice of Privacy Practices and a copy of the Practices Regarding Disclosure of Patient Health Information. I understand my health information will be used and disclosed consistent with these Notices.

___________________________________________________________________________________

Standards and Practices - Privacy of Patient Information

Standards

Iris Netzer, L.Ac. and her team at Acupuncture Remedies are committed to treating all patients with appropriate care and respect. Information that patients provide to use in connection with their treatment, Protected Health Information (PHI), is subjected to standards of security and confidentiality as defined under Federal Law, the Health Information Portability and Accountability Act (HIPAA). These Standards and Practices set forth the procedures in insure compliance with the requirements of HIPAA.

Practices

1. Written or electronic files containing PHI must be stored in secure facilities. Written files will be maintained in locked file cabinets and electronic files will be stored in secure databases only accessible through password- protected codes. Computer screens will be positioned so that they are not viewable by persons other than personnel authorized to access that information. All personnel shall use discretion when discussing PHI in conversations.

2. A Notice of Privacy Practices together with the statement of Practices Regarding Disclosure of PHI will be provided to all patients at the time of their initial visit. All patients will be requested to sign a statement acknowledging receipt of this information. The acknowledgement will be kept on file for seven years.

3. Patients will be requested to advise the office whether it may contact them by phone or in writing regarding their care. It is our practice to call to remind patients of their appointments and to send billing and related information to patients homes.

4. PHI may be routinely used for treatment, billing, payment and quality control purposes. PHI may also be used without the patients consent for the following purposes:

a. uses and disclosures required by law

b. uses and disclosures for public health activities

c. disclosures about victims of abuse, neglect or domestic violence

d. disclosures for judicial and administrative proceedings

e. disclosures for law enforcement purposes f. uses and disclosures about decedents

g. uses and disclosures for cadaver or organ donation purposes

h. uses and disclosures to avert a serious threat to health or safety

i. disclosures for workers compensation

j. disclosures to a State Licensing Board or other professional oversight entity

5. Patients have the right to request restrictions on the use of their PHI although, we are not always able to abide by such requests. All such requests must be submitted in writing on our Restriction Request Form. We will take all such requests under advisement and notify the patient in writing of our determination. A copy of the determination will be maintained in our files. If the request is granted then it will be observed, except in the event of an emergency or in the event we terminate the agreement.

6. State law pertaining to parent/guardian authorization will apply in the case of a minor. When state law is silent, we reserve the right to use our professional judgment.

7. Non-routine requests for PHI will be reviewed in the normal course and may require specific patient authorization.

8. Patients may request an account of all PHI disclosures made in the prior six years. Such an accounting will not include disclosures:

a. for treatment, payment and healthcare operations

b. to the patient

c. to persons involved in the patients care

d. for national security or intelligence purposes

e. to correctional institutions of law enforcement agencies

f. disclosures made prior to the enactment of HIPAA

In some instances PHI may be used once it has been stripped of all elements of personally identifying information. Identifiers that may be stripped include:

a. name

b. all address information

c. email addresses

d. dates (other than year)

e. Social Security number

f. medical record numbers

g. health plan beneficiary numbers

h. account numbers

i. certificate numbers

j. license numbers

k. vehicle identification numbers

l. facial photographs

m. telephone numbers

n. device identifiers

o. url’s

p. ip addresses

q. biometric identifiers

r. zip code, if the geographic unit includes less than 20,000 persons

s. any other unique data which when used alone or in combination with other information might identify the individual who is the subject of the information

9. We are required to act on written requests for onsite review of PHI within thirty days of our receipt of the request. If copies are requested we may charge a reasonable copying fee. Patients do not have the right to access:

a. psychotherapy notes

b. information relating to criminal, civil or administrative procedures

c. PHI lawfully prohibited from release because it is subject to or exempted from Clinical Laboratory Improvements Amendments (CLIC)

d. information created by someone other than us given to use under a promise not to release

10. Patients have a right to request amendments to their PHI. Requests to amend must be made in writing, clearly stating the requested amendment and the reason for the request. We will provide a written response within 60 days. If un-amended information had previously been provided to third parties, we will undertake to advise any such person of the amendment. If the request is denied we will provide a written statement setting forth the basis for the denial.

11. Amendment Rights do not apply in the following circumstances:

a. the information is not part of the patient file

b. the information is accurate and complete

c. the information was not created by us

12. We shall designate a person who shall be responsible for developing and implementing out HIPAA policies and procedures. This person shall also be responsible for training all staff in these policies and procedures. All employees will be required to sign an Employee Agreement Form acknowledging that they have been trained and they understand their obligations. Employee infractions of HIPAA will result in discipline and may result in termination of employment. Similarly, any third party vendor who has access to PHI will be required to

acknowledge that they are HIPAA compliant in all services provided to our business.

13. We shall not adversely treat any patient who exercises his/her rights under HIPAA. The staff is expressly prohibited from intimidating, threatening, coercing, discriminating, or retaliating against any patient who exercises their HIPAA rights.

14. Any patient wishing to appeal a determination or to file a complaint regarding HIPAA should contact the Secretary of DHHS within 180 days of the alleged violation. All personnel shall fully cooperate with any resulting investigation. Complaints are to be filed with:

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW Washington DC, 20201

800-368-1019 Hotline

___________________________________________________________________________________

Practices Regarding Disclosure of Patient Health Information

Your health information will be routinely used for treatment, payment and quality monitoring. Your consent is not required in these circumstances.

Treatment – Information obtained by us will be entered into your treatment record and used in the course of your treatment. Your health information may be shared with other health practitioners as we, in the exercise of our professional judgment, deem appropriate. Information regarding our assessment of your health and information regarding consultations may also be retained in your file.

Payment – Your record will be used to receive payment for services. A bill or other payment information may be mailed to your home or to a third party provider. That information will likely contain diagnostic determination, practitioner impressions and treatment procedures.

Quality Monitoring – We will use your health information to assess the care you have received and to compare outcomes. This information may also be used in conjunction with various scientific studies regarding your specific condition or Oriental Medicine itself.

The following disclosures are required by law and do not require your consent:

Food and Drug Administration (FDA) – We are required to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable produce recalls, repairs or replacements.

Workers Compensation – We will release health information to the extent required under the workers compensation law.

Public Health – We are required to disclose health information to public health entities or legal authorities responsible for tracking birth and morbidity, communicable disease, injury or disability and matters relating to organ/cadaver donations.

Law Enforcement – We are required to provide your health information to law enforcement and professional oversight personnel under state and federal law. Similarly, we will disclose such information in the event we believe there is a risk of harm to yourself or others.

We also consider the following uses as routine use and disclosure. If you do not want your health information used in the following circumstances, please advise us in writing.

Business Associates – Professionals and others whose services we require in the normal course of our business. Examples include our accountant, lawyer and pharmacy. We require these individuals to follow the same procedures and standards as our staff.

Communication with family – We may contact a family member or some other person designated by you to assist them in enhancing your well-being.

Marketing and Fundraising – We may periodically send information to you regarding treatment alternatives and other health related benefits we believe may be useful to you. We may also request your charitable support on behalf of alternative medicine research projects or other medically related chartable events. This contact will not disclose information regarding your specific medical condition.

*HIV / Aids
Yes No

Name of Adult Participant and/or Parent or Legal Guardian of Minor:

First Name:	Last Name:	Birth Date:
Address:	City:	State:
Zip:	Email:	Phone:

Relationship to minor:

Full name and birth date of family members under the age of 18

#1	First Name:	Last Name:	Birth Date:
#2	First Name:	Last Name:	Birth Date:
#3	First Name:	Last Name:	Birth Date:
#4	First Name:	Last Name:	Birth Date:
#5	First Name:	Last Name:	Birth Date:
#6	First Name:	Last Name:	Birth Date:
#7	First Name:	Last Name:	Birth Date:
#8	First Name:	Last Name:	Birth Date:
#9	First Name:	Last Name:	Birth Date:
#10	First Name:	Last Name:	Birth Date:

Date and Time Signed:

By checking this box I agree to have read and agree to the legal agreement above.

Send me emails about Account Management, Reminders, and Schedule Changes

Add text here.

Our Privacy Policy

PLEASE NOTE THAT WAIVERKING, INC.’S (“WaiverKing”) PRIVACY POLICY HAS CHANGED EFFECTIVE May 25th, 2018.

You acknowledge that this privacy policy is a part of our website’s Terms of Service, and by accessing or using our website, you agree to be bound by all of its terms and conditions. IF YOU DO NOT AGREE TO THESE TERMS, AS UPDATED, PLEASE IMMEDIATELY STOP ACCESSING THE WEBSITE.

This document explains how we use your personal data.

When you sign up to use this service provider’s services, you do so through software provided by us, WaiverKing.

We are committed to ensuring the privacy of all users of our software and services and other visitors to our website. In this policy we explain how we hold, process and retain your personal data.

In respect to the account data, waiver data, and payment data (as defined below) that you provide to us, we are acting as a data processor on behalf of the service provider, who will be acting as the data controller in respect to such data. We will never store or control this data. You should direct any requests or queries you have regarding this data to the data controller, your service provider.

1. How we use your personal data

1.1. This section provides you with information about:

a) what personal data we hold and process;

b) in respect of personal data that we did not collect from you directly, where we obtained that data from, and what types of data we have collected;

c) the purposes for which we may process your personal data; and

d) the legal grounds on which we process your data.

Members and end users of our services

1.2. Account data. We may process information about you that you provide to us when you first sign up with a service provider ("account data"). This account data may include your name, address, telephone number, email address, date of birth, gender, employment details, and a photograph of you. We may use this data to create your account with the service provider when you sign up. This account data may be updated each time you complete a document through our software. We do not process your account data in any other way, or have access to it in any way.

The legal basis for this processing is our legitimate interests in providing our services to our clients, and ensuring that your account is updated each time that you complete a document through our software.

1.3. Waiver data. If you are using our software in order to sign documents such as a waiver, health form, contract, or questionnaire, we may process information that you put into such documents (“waiver data”). This waiver data may include your name, signature, date of birth, email address, information about your health and medical history, and any other information that you are required or requested to put into the document.

Once you have completed the document, we will process it, convert the document into a different format, and send it to your account with the service provider in order for it to be stored. We will never store your data permanently on our systems (although it may be stored in your account with your service provider).

The purpose for our processing your data in this way is to maintain and administer a complete and accurate record of the documents that you have signed and completed for your service provider. The legal basis for our processing your waiver data (to the extent that such waiver data does not class as a special category of personal data), will be our legitimate interests in providing our services to our clients who have asked you to complete the document in question, in order to ensure that a complete and accurate record of your signing and completing the documents is maintained and administered.

1.4. Sensitive Personal Data. During the course of using our software and services and providing us with information in order for us to provide our services to you, you may provide us with sensitive information about yourself (“sensitive data”). This sensitive data may include your health and medical history. We may use this data for providing our services to you. However, we will only process this sensitive data if you consent to us doing so.

[The consent to use this information needs to be provided by the parent for children under the age of 13. Anyone over the age of 13 can provide consent for use of their data under GDPR]

We comply with the requirements of the Children’s Online Privacy Protection Act. You must be at least 18 years old to have our permission to use the WaiverKing website. If you are between the ages of 13 and 17, or under the age of majority where you live, you represent that your legal guardian has reviewed and agreed to this privacy policy.

Other processing that we may carry out

1.5. Website data. We may process data about your use of our website and services ("website data"). The website data may include your IP address, geographical location, browser type and version, operating system, referral source, length of visit, page views and website navigation paths, as well as information about the timing, frequency and pattern of your service use. The source of the website data is our analytics tracking system. This website data may be processed for the purposes of analyzing the use of the website and services.

The legal basis for this processing is our legitimate interests, namely monitoring and improving our website and services.

We may also process this data for the purposes of diagnosing any issues we detect in relation to the use of our products or services. This data may be collected by our error-tracking software which is provided by Rollbar. We always try to ensure that any such data is anonymized so that you cannot be identified before it is stored in our records.

The legal basis for this processing is our legitimate interests in monitoring and improving our products and services.

1.6. Enquiry data. We may process information contained in any enquiry you submit to us regarding our products or services ("enquiry data"). The enquiry data may be processed for the purposes of offering, marketing and selling relevant products and/or services to you.

The legal basis for this processing is our legitimate interests, namely dealing with and responding to your enquiry appropriately.

1.7. Notification data. We may process information that you provide to us for the purpose of subscribing to our blog and press releases ("notification data"). The notification data may be processed for the purposes of sending you newsletters.

Where you are a corporate customer, the legal basis for this processing is our legitimate interests, namely the marketing of relevant products and services to you.

1.8. Correspondence data. We may process information contained in or relating to any communication that you send to us ("correspondence data"). The correspondence data may include the communication content and metadata associated with the communication. Our website will generate the metadata associated with communications made using the website contact forms. The correspondence data may be processed for the purposes of communicating with you and record-keeping.

The legal basis for this processing is our legitimate interests, namely the proper administration of our website and business and communications with users.

1.9. Payment data. We do not process payment information relating to goods and services that you purchase from the service provider. However, we do capture certain data relating to your payments and use them to update your account with the service provider ("payment data"). The payment data may include your contact details, your card details and the transaction details. The payment data may be processed for the purposes of updating your account with the service provider. The legal basis for this processing is our legitimate interests, namely our interest in the proper administration of our software and ensuring your account with the service provider is updated.

1.10. Other processing activities. In addition to the specific purposes for which we may process your personal data set out above, we may also process any of your personal data where such processing is necessary for compliance with a legal obligation to which we are subject, or in order to protect your vital interests or the vital interests of another natural person.

2. Providing your personal data to others

2.1. To our clients and partner service providers. The only third parties that we will disclose your personal data to are our clients (your service provider) who is the data controller in respect to the account data, waiver data, and payment data that we collect about you, and MINDBODY Inc. (“MINDBODY”), who provide software services to service providers in conjunction with the WaiverKing software. Your accounts are created by WaiverKing in the MINDBODY software on behalf of our clients.

2.2. Our insurers/professional advisers. We may disclose your personal data to our insurers, legal counsel, and/or professional advisers insofar as reasonably necessary for the purposes of obtaining and maintaining insurance coverage, managing risks, obtaining professional advice and managing legal disputes.

2.3. Where we provide your personal data to any third party. Where we share your personal data with any of the third parties referred to above, we will ensure this processing is protected by appropriate safeguards including a suitable data processing agreement with that third party.

2.4. To comply with legal obligations. In addition to the specific disclosures of personal data detailed above, we may also disclose your personal data where such disclosure is necessary for compliance with a legal obligation we have to comply with, or in order to protect your vital interests or the vital interests of another individual. This may include disclosing your personal data in response to lawful requests by public authorities, including to meet national security or law enforcement requirements.

2.5. We take reasonable and appropriate steps to ensure that third-party agents and service providers process your personal data in accordance with our Privacy Shield obligations and to stop and remediate any unauthorized processing. Under certain circumstances and pursuant to applicable laws, we may remain liable for the acts of our third-party agents or service providers who perform services on our behalf for their handling of your personal data that we transfer to them.

3. Transfers of your personal data outside of the European Economic Area

As further detailed below, we may transfer your personal data to our servers based in the US, as we are part of the Privacy Shield. Otherwise, where your personal data is transferred outside of the EEA, we will ensure that either (a) The European Commission has made an "adequacy decision" with respect to the data protection laws of the country to which it is transferred, or (b) we have entered into a suitable data processing agreement with the third party situated in that country to ensure the adequate protection of your data. In all cases, transfers outside of the EEA will be protected by appropriate safeguards.

4. Retaining and deleting personal data

4.1. Personal data that we process for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes. Details about members of our clients (your service provider) and end users of our services, including the account data, waiver data and sensitive personal data, will not be stored by WaiverKing.

4.2. Unless we contact you and obtain your consent for us to retain your personal data for a longer period, we will retain and delete your personal data as follows:

a) Website data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

b) Enquiry data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

c) Notification data (other than Notification data that is also Contact data) will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

d) Correspondence data will be retained for 12 months following the date of our last contact or dealing with you, at the end of which period it will be deleted from our systems.

4.3. We may retain your personal data where such retention is advisory and/or necessary for compliance with a legal obligation to which we are subject (such as with regard to applicable statutes of limitations, litigation or regulatory investigations), or in order to protect your vital interests or the vital interests of another natural person.

5. Your rights

5.1. You may instruct us to provide you with any personal information we hold about you; provision of such information will be subject to:

a) your request not being found to be unfounded or excessive, in which case a charge may apply; and

b) the supply of appropriate evidence of your identity (for this purpose, we will usually accept a notarized photocopy of your driver’s license and/or passport and an original copy of a utility bill showing your current address).

5.2. We may withhold personal information that you request to the extent permitted by law.

5.3. You may instruct us at any time not to process your personal information for marketing purposes.

5.4. In practice, you will usually expressly agree in advance to our use of your personal information for marketing purposes, or we will provide you with an opportunity to opt out of the use of your personal information for marketing purposes.

5.5. Your right to access your data. You have the right to ask us to confirm whether or not we process your personal data and, to have access to the personal data, and any additional information. That additional information includes the purposes for which we process your data, the categories of personal data we hold and the recipients of that personal data. You may request a copy of your personal data. The first copy will be provided free of charge, but we may charge a reasonable fee for additional copies.

5.6. Your right to correct. If we hold any inaccurate personal data about you, you have the right to have these inaccuracies corrected. Where necessary for the purposes of the processing, you also have the right to have any incomplete personal data about you completed.

5.7. Your right to erasure. In certain circumstances you have the right to have personal data that we hold about you erased. This will be done without undue delay. These circumstances include the following: (1) it is no longer necessary for us to hold those personal data in relation to the purposes for which they were originally collected or otherwise processed; (2) you withdraw your consent to any processing which requires consent; (3) the processing is for direct marketing purposes; and/or (4) the personal data have been unlawfully processed. However, there are certain general exclusions of the right to erasure, including where processing is necessary: for exercising the right of freedom of expression and information; for compliance with a legal obligation; or for establishing, exercising or defending legal claims.

5.8. Your right to restrict processing. In certain circumstances you have the right for the processing of your personal data to be restricted. These circumstances include the following: (1) you do not think that the personal data we hold about you is accurate; (2) your data is being processed unlawfully, but you do not want your data to be erased; (3) it is no longer necessary for us to hold your personal data for the purposes of our processing, but you still require that personal data in relation to a legal claim; and/or (4)you have objected to processing, and are waiting for that objection to be verified. Where processing has been restricted for one of these reasons, we may continue to store your personal data. However, we will only process it for other reasons: with your consent; in relation to a legal claim; for the protection of the rights of another natural or legal person; or for reasons of important public interest.

5.9. Your right to object to processing. You can object to us processing your personal data where our legal basis for the processing is that it is necessary for: the performance of a task carried out in the public interest, or in the exercise of any official authority vested in us; or the purposes of our legitimate interests or those of a third party. If you make an objection, we will stop processing your personal information unless we are able to: demonstrate compelling legitimate grounds for the processing, and that these legitimate grounds override your interests, rights and freedoms; or the processing is in relation to a legal claim.

5.10. Your right to object to direct marketing. You can object to us processing your personal data for direct marketing purposes. If you make an objection, we will stop processing your personal data for this purpose.

5.11. Your right to data portability. Where you have given us consent to process your personal data, or where we are processing your personal data for the performance of a contract, you have a legal right to receive a copy of the personal data we hold about you in a structured, commonly used and computer readable format. When a data request is made of us we will make available all applicable personal data to you in a computer readable format and will transmit your personal data to the appropriate third party pursuant to your instruction. We will not process your data in this way if we believe that it may pose a threat to the security of the data.

5.12. Your right to object for statistical purposes. You can object to us processing your personal data for statistical purposes on grounds relating to your particular situation, unless the processing is necessary for performing a task carried out for reasons of public interest.

5.13. Automated data processing. To the extent that the legal basis we are relying on for processing your personal data is consent, and where the processing is automated, you are entitled to receive your personal data from us in a structured, commonly used and computer-readable format. However, you may not have this right if it would adversely affect the rights and freedoms of others.

5.14. Complaints to a supervisory authority pursuant to the GDPR. If you think that our processing of your personal data infringes data protection laws, you can lodge a complaint with a supervisory authority responsible for data protection. You may do this in the EU member state of your habitual residence, your place of work or the place of the alleged infringement. This provision is only applicable if you are subject to the protections of the GDPR.

5.15. Complaints if you are not subject to the protections of the GDPR. If you think that our processing of your personal data infringes data protection laws you may contact us via email at privacy@waiverking.com or mail at: WaiverKing, Inc. 340 S Lemon Ave # 2018 Walnut, California 91789.

5.16. Right to withdraw consent. To the extent that the legal basis we are relying on for processing your personal data is consent, you are entitled to withdraw that consent at any time. Withdrawal will not affect the lawfulness of processing before the withdrawal.

5.17. Exercising your rights. You may exercise any of your rights in relation to your personal data by written notice to us in addition to the other methods specified above.

5.18. Point of Contact Data. PARAGRAPHS 5.1 – 5.17 SHALL NOT APPLY TO ACCOUNT DATA, WAIVER DATA, OR PAYMENT DATA OBTAINED OR PROCESSED BY WAIVERKING. IN RESPECT OF SUCH DATA:

a) WAIVERKING IS ACTING AS A PROCESSOR OF THAT DATA AND THE MAIN CONTRACTOR IS THE CONTROLLER;

b) YOU SHOULD CONTACT THE SERVICE PROVIDER TO EXERCISE THE RIGHTS SET OUT IN THIS PARAGRAPH 5

6. Links To Other Websites. Except as otherwise discussed in this privacy policy, this document only addresses the use and disclosure of information we collect from you. Other websites accessible through our website have their own privacy policies and data collection, use, and disclosure practices. Please consult each website’s privacy policy. We are not responsible for the policies or practices of third parties, including any third-party site or other products and services used in connection with WaiverKing’s services. The inclusion of a link does not imply endorsement of the linked site or service by us or by our affiliates.

We are not responsible for the collection, usage and disclosure policies and practices (including the data security practices) of other organizations, such as, Apple, Google, Microsoft, or any other operating system provider, wireless service provider or device manufacturer, including any personal data you disclose to other organizations through or in connection with WaiverKing’s services.

7. Security of Your Information. The security of personal data is a high priority at WaiverKing. We seek to use reasonable technical, administrative and physical safeguards to protect personal data within our organization. Unfortunately, no data transmission or storage system can be guaranteed to be 100% secure. As a result, while we strive to protect your personal data, you acknowledge that: (a) there are security and privacy limitations of the Internet which are beyond our control; (b) the security, integrity, and privacy of any and all information and data exchanged between you and us through the website cannot be guaranteed; and (c) any such information and data may be viewed or tampered with in transit by a third party.

8. IP Addresses and Cookies. Cookies are very small text files that are stored on your computer when you visit some websites.

We use cookies to help identify your computer, including where available, your IP address, operating system and browser type, for system administration so we can keep your activity secure, tailor your user experience and remember your preferences. This is statistical data and does not identify any individual. You are always free to decline our cookies if your browser permits, but some parts of our website may not work properly.

9. Your California Privacy Rights: Notice to California Customers and Opt-Out Information. Residents of the State of California, under certain provisions of the California Civil Code, have the right to request from companies conducting business in California a list of all third parties to which the company has disclosed certain personal data, as defined under California law, during the preceding year for third party direct marketing purposes. You are limited to one request per calendar year. In your request, you must supply appropriate evidence of your identity and attest to the fact that you are a California resident and provide a current California address for our response. You may request the information by writing to privacy@waiverking.com

Some web browsers incorporate a “Do Not Track” feature that signals to websites that you visit that you do not want to have your online activity tracked. California residents are entitled to know how WaiverKing, Inc. responds to “Do Not Track” signals. How browsers communicate the Do Not Track signal is not yet uniform, so a standard technological response has not yet been developed by the appropriate technology communities. For this reason, we do not respond to Do Not Track signals currently. To opt out of direct advertising on our website, please send a request to the address above. The effect of an opt-out will be to stop direct advertising, but it will still allow the collection of usage data for certain purposes (e.g., research, analytics, and internal online services operation purposes).

10. Privacy Shield Framework

10.1. WaiverKing Inc. complies with the EU-U.S. and Swiss-U.S. Privacy Shield Framework as set forth by the U.S. Department of Commerce regarding the collection, use, and retention of personal information transferred from the European Union and Switzerland to the United States. WaiverKing has certified to the Department of Commerce that it adheres to the Privacy Shield Principles. If there is any conflict between the terms in this privacy policy and the Privacy Shield Principles, the Privacy Shield Principles shall govern. To learn more about the Privacy Shield program, and to view our certification, please visit https://www.privacyshield.gov/

10.2. In compliance with the Privacy Shield Principles, WaiverKing commits to resolve complaints about our collection or use of your personal information. Any individual(s) with inquiries or complaints regarding our Privacy Shield policy should contact us at: privacy@waiverking.com

10.3. WaiverKing Inc. has further committed to refer unresolved Privacy Shield complaints to Judicial Arbitration and Mediation Services (JAMS), an alternative dispute resolution provider located in the United States. If you do not receive timely acknowledgment of your complaint from us, or if we have not addressed your complaint to your satisfaction, please visit https://www.jamsadr.com/eu-us-privacy-shield for more information or to file a complaint. The services of JAMS are provided at no cost to you. In certain situations, you may also have the right to pursue binding arbitration under the Privacy Shield Framework.

10.4. You may have the option to select binding arbitration for the resolution of your complaint under certain circumstances, provided you have taken the following steps: (1) raised your complaint directly with WaiverKing Inc. and provided us the opportunity to resolve the issue; (2) made use of the independent dispute resolution mechanism identified above; and (3) raised the issue through the relevant data protection authority and allowed the U.S. Department of Commerce an opportunity to resolve the complaint at no cost to you. For more information on binding arbitration, see U.S. Department of Commerce's Privacy Shield Framework: Annex I (Binding Arbitration).

10.5. For purposes of enforcing compliance with the Privacy Shield, WaiverKing is subject to the investigatory and enforcement authority of the U.S. Federal Trade Commission.

10.6. WaiverKing Inc. is controlled and operated by us from the United States. Except where you are a resident of a Member State of the EU, in which case paragraphs 2 and 3 above will apply, your personal data may be stored and processed in any country in which we engage service providers, and by using WaiverKing’s services you understand that your information may be transferred to countries outside of your country of residence, including the United States, which may have data protection rules that are different from those of your country. In certain circumstances, courts, law enforcement agencies, regulatory agencies or security authorities in those other countries may be entitled to access your personal data. Regardless of where your information is processed, we apply the same protections described in this policy.

11. Changes to the privacy policy. We reserve the right to change this policy at any time, without prior notice to you. Such changes, modifications, additions, or deletions shall be effective immediately upon notice thereof, which may be given by means including, but not limited to, issuing an e-mail to the e-mail address provided by you or posting the revised policy on this page. You acknowledge and agree that it is your responsibility to maintain a valid e-mail address and/or review the WaiverKing website and this policy periodically, and be aware of any modifications. Your continued use of the WaiverKing website after such modifications will constitute your: (a) acknowledgment of the modified policy; and (b) agreement to abide and be bound by the modified policy.

12. Our details

12.1. This website and software is owned and operated by WaiverKing Inc.

12.2. We are registered in the state of California under registration number C3518177, and our registered office is at 340 S Lemon Avenue, # 2018 Walnut, California 91789.

12.3. You can contact us:

a) by mail, using the postal address given above;

b) using our website contact form;

c) by telephone, on the contact number published on our website from time to time; or

d) by email, using the email address published on our website from time to time.

13. Data protection officer

Our data protection officer may be contacted via email: privacy@waiverking.com, or telephone: +1 (888) 211-6693.

Your browser is not supported. Please update your browser

Fill in Adult/Legal Guardian Info

Fill in Billing Info

Fill in Children Info

Full name and birth date of family members under the age of 18

Your browser is not supported. Please update your browser

Sign Patient Intake Form

Please fill out information about yourself.

Your information

Fill in Adult/Legal Guardian Info

Fill in Billing Info

Fill in Children Info

Please read the content below then scroll to the bottom of the intake form to sign

Name of Adult Participant and/or Parent or Legal Guardian of Minor:

Full name and birth date of family members under the age of 18