Consent for Treatment: By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from Acupuncture Connections by a licensed acupuncturist of Acupuncture Connections, Inc. I understand that acupuncturists practicing in the state of Massachusetts are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, spontaneous miscarriage, pneuomothorax and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time. I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy.
Chinese Herbs: I understand that substances from Acupuncture Connections may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effects may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call Acupuncture Connections as soon as possible.
Acknowledgement of Notice of Privacy Practices: I have been presented with a copy of The Notice of Privacy Policies for the office of Acupuncture Connections. I understand how this clinic may use or disclose my health information. I understand when this medical office may not use or disclose my health information. I understand my health information rights and understand that this office reserves the right to change this notice of privacy practices. I also understand how to place a complaint regarding this notice and have also been provided the opportunity to review and question the privacy policies of this clinic.
Late Cancellation / No Show Policies: a minimum of 24 hours is required to reschedule or cancel an appointment. Unless otherwise agreed upon in advance or in the case of inclement weather, the full price of an acupuncture session or one session from a treatment package or membership will be deducted for each missed appointment. Email reminders are sent 48 hours before each session.
If a massage session is cancelled less than 24 hours you will be charged 50% of your session. Our staff calls to confirm this appointment 48 hours before as a reminder, in addition to the email reminder that each patient receives.
There is a $30 fee for returned checks.
I have carefully read and understand all of the above information and am fully aware of what I am signing. I give my permission and consent to treatment. 7/01/2011