To assist you with the best possible care, please fill out this form as accurately as you can. All information provided will be kept confidential.
I understand that I am responsible for attending my appointment and for paying a missed appointment fee if I do not give 24 hours notice to change or cancel my appointment. Many extended health plans have an allowance for Acupuncture treatments; the amount varies depending on the plan. It is also possible to obtain coverage through MSP, DND and DVA. I consent to communication with Black Spruce Acupuncture via email for appointment reminders (and can unsubscribe at any time).
I HEREBY CONSENT to treatment, namely acupuncture and/ or related therapies such as gua sha or cupping to be performed by Alix Jean B.Sc., R.Ac. I understand that one- time disposable needles are used in all treatment and that there may be a chance of bruising, dizziness or slight soreness at some acupuncture points following treatment, therefore it is recommended to leave time after my appointment before driving, and also recommended to eat before treatment.
Acupuncture is generally very safe. I will be consulted prior to the use of any acupoints that may be potentially dangerous or any treatment protocols that may cause any ill effects, and I will indemnify the acupuncturist for any harm caused by or due to acupuncture treatment.
The information on this form is complete and true to the best of my knowledge, and I have read and understood the above consent for treatment.
Welcome to Black Spruce Acupuncture! I am delighted to have you as a new patient and look forward to providing you with the highest quality of care.