I, _____________________________________, consent to receive naturopathic care, acupuncture and recommendations from Shana Deneen, ND, Dipl.Ac. I understand that I will not be receiving diagnostic information from my Naturopathic Doctor (ND). Dr. Shana Deneen is licensed as a naturopathic physician in the state of Arizona and she received her four years of post-graduate naturopathic medical education through CMNE approved programs. I understand that the state of Oklahoma does not license NDs and that Dr. Shana Deneen is not a Medical Doctor (MD) nor Osteopathic Doctor (DO). I also understand that I will not be receiving any medical treatment or prescriptions from Dr. Shana Deneen.
I understand that the information I share with Dr. Shana Deneen, will be kept confidential with the following exceptions: (1) Information regarding dangerous or illicit alcohol or drug use; (2) Disclosure of child, elder or other abuse; (3) Disclosure of intent to harm oneself or others. Dr. Deneen will report the above exceptions to the Oklahoma Department of Human Services (DHS); (4) In the event of an emergency where your emergency contact needs to be notified and/or emergency services need to be notified to provide medically necessary care for you in the event that you are unable to execute this on your own. I understand that if Dr. Deneen determines that I am in urgent need of medical evaluation, she will refer me to my primary care physician or the Emergency Room. I understand that I must consult with my licensed medical provider to obtain medical evaluation, medical diagnosis, and medical treatment.
Acupuncture is the insertion of a thin needle into the surface of the body. A patient may feel a slight pricking sensation and/or an electrical impulse near the needle. Patients usually report little or no pain during the acupuncture treatment. On occasion, there may be slight bruising where a needle was inserted. The duration of a treatment is typically 30 minutes to one hour. Although no outcome of treatment can be guaranteed, it is understood that every patient is unique and each treatment is designed specifically for the conditions of the patient. I understand that I have the right to consent to, or refuse treatment.
We accept payment via cash, check or credit card. Payment is due at the time that services are provided. Failure to make payment at the time of service will result in a requirement to prepay all future visits with cash only
Initial Acupuncture appointments are priced at $165, follow up visits are $90. Initial Naturopathic consultations are priced at $195, follow up visits are $90. Your appointment time is reserved for you. Should you need to reschedule or cancel, please do so at least 24 hours prior to your appointment to avoid a cancellation fee equal to your appointment cost.
Signing my name below attests to my understanding of the above policies.