I have read and understand this form and acknowledge that the purposes, goals, techniques, procedures, limitations, potential risks and benefits of the service(s) to be performed have been explained to me. I have also received the Notice of Privacy Practices and the accompanying Practices Regarding Disclosure of Client Health Information. I understand my health information will be used and disclosed consistent with the Notice, and that I have the right to request restrictions on certain uses and disclosures of my health information. Further, I have felt free to ask my practitioner questions regarding the proposed services and other pertinent information, including questions about him or her, and have received satisfactory explanations. I understand that I am free to discontinue services(s) at any time.
Services to be Provided
I understand that acupuncture serves individuals with a wide range of complaints including both acute and chronic healthcare issues. I understand that I may be treated with the insertion of needles and/or with the application of heat to the skin.
Risks/Possible Side Effects/Healing Response
I understand that acupuncture may result in certain side effects, including local bruising, slight bleeding, fainting, temporary pain and discomfort, and temporary aggravation of symptoms existing prior to treatment.
I know that each person is unique and has ultimate responsibility for his or her own healthcare. I acknowledge that I have not received any guarantees or promises as to the results or success that will be obtained from the services provided.
Infectious Disease Prevention
I understand infectious diseases are carried through the air, through physical contact, and through body fluids. I understand that my practitioner follows universally prescribed precautions and procedures (such as clean needle technique and hand washing) to prevent the spread of infectious disease.
I understand that it is my responsibility as a client to inform my practitioner about all aspects of my health and that, as service progresses, to inform my practitioner of changes that occur. If I experience any pain, discomfort or adverse side effects, it is my responsibility to immediately notify my practitioner. Additionally if I currently have any infectious disease (cold, flu, intestinal virus etc.) or rash that I am aware of, I am to notify the practice prior to my appointment.
I recognize that my acupuncturist is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. I am free to consult a medical doctor or any other licensed practitioner at any time, I understand also that if there is an emergency, or a worsening of my health condition, or if a new ailment or condition arises, that I should consult a licensed physician.
Initial Consultation — $150.00
Acupuncture Treatment — $100.00
Late Cancellation/Missed Appointment Charge — $100.00 (Late cancellation is less than 24 hours notice)
Payment of cash or check is due at the time of service.
Because health insurance is an arrangement between you and your insurance company, you should contact your insurance company’s representative to determine if coverage will be provided for your treatments. It is my policy that patients file for reimbursement with their insurance carriers. I can provide you with an appropriate Patient Receipt for filing. If you plan to seek reimbursement, please let me know so that a Diagnostic Code may be assigned.