Acupunture with Breta.Pdf

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ACUPUNCTURE CONSENT FORM I, _____________________________________, voluntarily consent to be treated with acupuncture by ______________________________. I understand that acupuncture involves the following The insertion of sterile disposable needles through the skin, with or without electrical stimulation. Moxabustion, the application of heat to acupuncture points. Massage techniques such as tui na, shiatsu, or zero balancing. Cupping, either static or moving. The skin is marked for 3-4 days. Gua sha, a scraping technique, which marks the skin for up to 3-4 days. Blood letting, which involves the use of a lancet to extract tiny drops of blood form acupuncture points. I will inform my practitioner about any circulatory or clotting disorders or use of blood thinners. Cupping and gua sha should not be done under these circumstances. I understand that it is important to have eaten before treatment. It is not advisable to receive treatment if extremely hungry, weak, or intoxicated. I have been informed that although rare, certain side-affects may result from my acupuncture treatment. These could include some minor discomfort, localized bruising, temporary aggravation of pre-existing conditions, fainting, diarrhea, and nausea. CANCELLATION POLICY I agree to pay MassageCraft in full if I fail to cancel my appointment within 24 hours. This includes insurance clients. MassageCraft cannot bill insurance for services not rendered. Initials____ INSURANCE COVERAGE I understand that if MassageCraft bills my insurer for services rendered that I am responsible for any unpaid balance including co-pays and charges applied to my deductible, (Workers Compensation claims excepted.) Initials____ I authorize insurance payments of medical benefits to MassageCraft INC. Initials____ Your insurance company may require medical reports documenting your treatment and progress. Your initials authorize release of medical information necessary to process your claim. Initials____ By signing below I understand and abide by the above policies and procedures. Signature______________________________________ Date ___/___/___ .

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