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Alpha Gal Intake

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Alpha-Gal Patient Intake Form

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Informed Consent to SAAT Treatment
I voluntarily consent to Soliman Auricular Allergy Treatment (SAAT) and related procedures provided by Dr. Russell McDaniel, D.C. and licensed practitioners at Family Chiropractic of the 4-States. I understand that SAAT is a specialized auricular (ear) acupuncture protocol developed by Dr. Nader Soliman, designed to address allergic responses, including Alpha-Gal Syndrome, by stimulating specific points on the ear corresponding to particular allergens.
Description of Treatment
SAAT treatment may include, but is not limited to, the following procedures as determined to be appropriate by the treating practitioner: the insertion of a single sterile semi-permanent needle or press tack needle into a specific point on the ear, which remains in place for approximately three to four weeks; identification and testing of specific allergens prior to treatment; and follow-up evaluation to assess response and determine the need for additional treatment cycles.

I understand that each allergen is typically treated individually, and that multiple sessions may be necessary depending on the number of allergens being addressed. Alpha-Gal Syndrome specifically relates to an allergic response to a sugar molecule found in red meat and certain mammalian products, and treatment is aimed at reducing the body's sensitization to this trigger.

Potential Benefits

SAAT has been used to address a variety of allergic conditions including, but not limited to, Alpha-Gal Syndrome, environmental allergies, food sensitivities, and related immune responses. Potential benefits may include reduced allergic reactivity, decreased sensitivity to identified allergens, and improved overall quality of life. However, no specific outcome or result can be guaranteed, and treatment is designed specifically for each individual patient.

Possible Risks and Side Effects

While SAAT is generally considered safe, I understand that certain risks may be associated with treatment. These may include, but are not limited to: minor discomfort, tenderness, or bruising at the needle site; infection at the needle site if proper care instructions are not followed; dizziness or lightheadedness; temporary worsening of allergic symptoms during treatment; and in rare cases, an allergic reaction to the needle material. Every effort is made by our practitioners to maintain a sterile environment and minimize risk.

I understand that it is my responsibility to inform the practitioner prior to treatment if I have any of the following: a bleeding disorder or am taking blood-thinning medications, a pacemaker or other implanted electrical device, am pregnant or trying to become pregnant, have a known sensitivity or allergy to metals, have an active infection or inflammation near the ear, or have any serious medical conditions that may affect treatment.

Needle Care Instructions

While the semi-permanent needle is in place I understand that I must keep the ear dry, avoid touching or manipulating the needle, monitor the site for any signs of infection such as redness, swelling, or discharge, and contact the office immediately if any concerning symptoms develop. I understand that if the needle falls out before my follow-up appointment I should contact the office.

Financial Policy & Cancellation Policy

Insurance coverage is not available for SAAT treatment. All treatment costs are the responsibility of the patient, and payment is due at the time of service for each session.

I understand that Dr. Russell McDaniel, D.C. reserves the right to charge for appointments that are missed or cancelled without at least 24 hours' notice, including no-call and no-show appointments. Charges for missed appointments are handled on a case-by-case basis at the discretion of the office.

Notice of Privacy Practices (HIPAA)

Family Chiropractic of the 4-States is required by law to maintain the privacy and confidentiality of your protected health information (PHI). We are also required to provide patients with notice of our legal duties and privacy practices with respect to your PHI. We make every reasonable effort to protect the privacy and confidentiality of all patient health information against unauthorized use or disclosure, as required by HIPAA. The complete Notice of Privacy Practices is available upon request via email, fax, or in person at our office.

Patient Acknowledgment & Consent

By signing below, I confirm that I have read and fully understand all of the above, including the Informed Consent to SAAT Treatment, Financial Policy, Cancellation Policy, and Notice of Privacy Practices (HIPAA). I understand the nature, purpose, potential benefits, and risks of SAAT treatment and have had the opportunity to ask questions.

Diagnosis and History

Have you been formally diagnosed with Alpha-gal Syndrome
Who diagnosed you?
Are you currentlyunder the care of an allergist?
Was your Alpha-Gal triggered by a tick bite?
Have you had an Alpha-gal IgE Bloodtest?
Are you pregnant?
Do you have a metal allergy?
Do you have an autoimmune disease?

Symptoms

Please check all symptoms you currently experience or have experienced:
How long after consuming a trigger food do your symptoms usually begin?
How would you rate the severity of your symptoms overall?
Have you ever experienced anaphylaxis?*
Please select at least one option
Do you carry and epinephrine auto-injector (EpiPen)?

Trigger Identification

Please check all known triggers that cause a reaction: 

Meats*
Please select at least one option
Dairy and Animal Products*
Please select at least one option
Other triggers

Current Management

Are you currently following a mammlian free diet?
How strictly are you able to avoid triggers?
Are you currently working with any other healthcare providers for your Alpha-Gal?
Are you currently taking any medications or supplements related to Alpha-gal?
Have you tried any other treatments for Alpha-gal prior to this visit?

Goals and Expectations

Patient Certification

I certify that all information I have provided on this intake questionnaire is true and accurate to the best of my knowledge. I understand that it is my responsibility to inform Dr. McDaniel of any changes to my health history, symptoms, or medications at any time during my care.

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

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Email:  support (at) reviewwave.com

Family Chiropractic of the Four States

Address

3301 N. Range Line Rd.,
Joplin, MO 64801

Phone

417-206-2225

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Location

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Address

3301 N. Range Line Rd.
Joplin, MO 64801, US

Contact Information 417-206-2225

[email protected]

We look forward to hearing from you

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Please do not submit any Protected Health Information (PHI).

Monday  

8:00 am - 12:00 pm

2:30 pm - 5:30 pm

Tuesday  

11:00 am - 3:00 pm

Wednesday  

8:00 am - 12:00 pm

2:30 pm - 5:30 pm

Thursday  

Closed

Friday  

8:00 am - 12:00 pm

2:30 pm - 5:30 pm

Saturday  

Closed

Sunday  

Closed

3301 N. Range Line Rd.
Joplin, MO 64801, US

417-206-2225