Acupuncture and Oriental Medicine Treatment Consent Form
I request and consent to the performance of acupuncture and other Chinese medicine procedures. I understand that my signature on this form indicates that I have read the following, and understand that if I have any questions about this information, I should ask the practitioner. It is my choice to receive acupuncture. I understand that acupuncture is an aid to health and wellbeing, and in no way takes the place of a doctor’s care when it is indicated. I agree to communicate with the practitioner any time I feel my well-being is being compromised. I understand that acupuncturists do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment. I have stated all medical conditions that I am aware of and I will update any changes in my health status during the course of my treatment.
Nature of Treatment: The treatment modalities may include acupuncture, massage therapy, acupressure, cupping, gua-sha, electric acupuncture, Chinese herbs. I understand that the treatments will be explained to me prior to treatment for my condition.
Purpose of Treatment: I understand that the purpose of the treatment is to resolve my condition, the reason that I am requesting treatment. The procedures used will attempt to remedy bodily dysfunction or diseases, to modify or prevent the perception of pain, and to make normal the body’s physiological functions.
Risks of Treatment: I understand that Chinese medicine procedures have been shown to be safe and effective. However, I understand that there are some uncommon risks. These may include:
Use of Disposable Needles: I understand that to prevent any possibility of infection from acupuncture, all needles used are pre-sterilized, one time use, surgical stainless steel needles that are disposed of after usage as medical waste. Needles are never reused.
Unforeseen Risks: I understand that the practitioner cannot anticipate or explain all risks and complications which may occur during or after treatment. I understand that they will exercise judgment based upon their determination of my best interests. I understand that I may stop treatment at any time.
Patient advisory to consult a physician: To comply with Article 160, section 8211.1 (b) of NYS Education law, we must advise that you consult a physician regarding your condition.
HIPAA Privacy Act: Ensures that all of your personal and health information remains confidential at all times between this office, your insurance company and you only. Should you have any questions about the privacy of your information at this office, you may ask Lianne C. DeMieri at any time.
I hereby waive and release the Acupuncturist, Lianne C. DeMieri of Centered Stillness Acupuncture and Massage Therapy, PLLC from any liability for ailments or injuries resulting from acupuncture due to prior ailments or injuries listed or omitted by me on this Health History Form.
Payment and Fees: Please note that other modalities such as cupping therapy, moxibustion, gua sha and the use of Infrared heat lamp may need to be incorporated during treatment to facilitate the treatment's effectiveness. Patients may also need front and back treatment depending upon condition. Some of these procedures may incur an extra charge that will be disclosed to you before administering.Payment is due at the time of service. Cash, checks, and credit cards are accepted. Please note there is a $30 fee for returned checks. Clients are responsible for the cost of any services not covered by their Health Insurance, Worker’s Compensation, or Disability Insurance.
Cancellation Policy: Centered Stillness Acupuncture & Massage Therapy, PLLC requires notice of at least 24 hours for the cancellation of an appointment. Services canceled with less than 24 hours notice will incur a 50% service fee.
Centered Stillness Acupuncture & Massage Therapy, PLLC respects the time of all of our clients. In the event you arrive late for an appointment, your session cannot be extended beyond the scheduled time frame. The remaining time left will be utilized for your treatment and the full fee will be charged.
We realize that illness or emergency situations can arise and exceptions to this policy are made at our discretion. We reserve the right to refuse providing treatment if it poses risks to your emotional or physical health, re-schedule your appointment in the event of tardiness, if it is determined that the client seems to be under the influence of drugs or alcohol, or to end a treatment at any time for inappropriate conduct.
Your signature indicates that you have read, understand and agree with the above information.
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Document Name: Acupuncture and Oriental Medicine Treatment Consent Form
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