Please fill out and submit the form below at least 24 hours before your first appointment.
I hereby agree and consent to the performance of Acupuncture, Traditional Chinese Medicine and related modalities performed by a Registered Acupuncturist. I understand that such procedures may include, but are not limited to: Acupuncture, Moxibustion, Cupping, Electrical Acupuncture, Gua sha, Tuina.
I understand that while generally painless there are possible side effects from the above mentioned treatments such as: bruising, numbness or tingling, dizziness or fainting, weakness, tiredness, nausea, minor swelling, bleeding, temporary pain or discomfort, hematoma at puncture site or blistering at Moxabustion site. A sensation of light-headedness may occur after acupuncture treatment and/or temporary aggravation of existing symptoms.
By voluntarily signing below I hereby certify that I have read this entire form, have been informed about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions with regards to the modalities described above. Additionally, I have consulted with a physician or dentist (as appropriate) about the condition for which acupuncture treatment is now being sought.
I intend this consent form to cover the entire course of treatment to be performed for my present condition and for any future condition(s) for which I seek treatment. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify or change the treatment plan.
I understand that there is a 24 hour cancellation policy. I may be charged up to the full cost of treatment if I miss or cancel an appointment with less than 24 hours notice.
Click on the image below to download the Intake Form. Please print and complete the form before your appointment.