3. Fee Schedule and Clinic info (signature)

iowa acupuncture clinic

8230 Hickman Road, suite B

Clive, Iowa 50325

Cell/text 515-331-8948
Clinic Information Form

Please read this important document about the iowa acupuncture clinic. This form requires our signature, please sign below. If you have any questions, please contact our clinic.
Patient Name:

First Name, Middle Initial Last Name
Patient Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearThis is important to properly identify the patient.
Patient mobile phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Contact email
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The iowa acupuncture clinic operates as a holistic traditional oriental medical clinic, specializing in acupuncture therapies, herbal medicine, lifestyle counseling and holistic health education.

We honor the holistic nature of life and one's health.

The iowa acupuncture clinic seeks to aid its patients in achieving a greater level of health and well-being. We focus on the individual person, educating them according to an ancient holistic style of oriental medicine. Most impor- tantly, the iowa acupuncture clinic seeks to care for the individual needs of each person.

The iowa acupuncture clinic was founded in 1997 by Elizabeth and William Terrell, L. Ac, MSOM., who:
1. were educated in Oriental Medicine at the prestigious Southwest Acupuncture College in Santa Fe, New
2. possess Master of Science Degrees in Oriental Medicine (Elizabeth MSOM '95, William MSOM '96),
3. maintain Acupuncture Certification through the NCCAOM (dipl. Ac. ); and
4. are Licensed Acupuncturists (L.Ac in Iowa.
In an effort to provide our clients with the best care, we request that you follow these guidelines:
1. The iowa acupuncture clinic is maintained as a peaceful, quiet healing space. Please limit noise and disturbances.
2. If you ever need any urgent attention, please speak as loudly as necessary.
3. We love and honor children as clients and guests. Please ask to wait with your child in our pediatric treatment area. Please leave the space as tidy as you found it.
4. Please place cell phones and other electronics on mute, and limit their use to necessity.
5. We maintain a toxin free environment for our staff and clientele who have environmental sensitivities. Please limit your use of cologne and perfume. Smoking is not permitted anywhere on our premises. If you have any special environmental needs, please let us know.
6. Payment is due upon completion of visit to clinic. Prompt payment discounts will be applied to any payments made at time of completion of visit. Please inform our staff, prior to treatments, if you will not be paying in full. Please ask for a receipt or insurance form for third-party reimbursement.
7. We all are human and make mistakes, please forgive us ours and we will respect yours.
8. The iowa acupuncture clinic is a health education and lifestyle center. We honor all questions.
(iowa acupuncture clinic info and guidelines page 2)

Acupuncture Treatment Guidelines

acupuncture is one of our clinic's most popular treatments, it is also it's most unique; as such, please observe the following guidelines when receiving treatment:
1. It is best to wear comfortable, loose fitting clothes. During a treatment, we might need to access various parts of your body, usually your arms, legs, abdomen and back. If you are coming from work, we have hangers for your business clothes and we will provide you with a cover during your treatment.
2. Be sure to eat something during the mealtime prior to your visit. It is very important to have nourishment in your system dur- an acupuncture treatment. Acupuncture utilizes your body's energy much like an exercise session would, and if your blood ing sugar is low, you will not respond as quickly to the acupuncture treatments. Please ask us for a snack if you need one.
3. Allow plenty of time for your visit. You will need to spend about 11/2 to 2 hours at the clinic during your initial visit. This time allows you to complete our initial paperwork, and allows us to ask you many questions, obtain an accurate diagnosis of your condition and give you an acupuncture treatment. Most of your return visits will last about 1 hour to 1¹/2 hours. Please let us know if you require a quicker treatment.
4. The practice of acupuncture is a licensed medical specialty in the State of Iowa. As such, it is regulated by the Iowa Board of MedicalExaminers, located at 400 SW 8th Street, Suite C, Des Moines, Iowa 50309-4686, phone: 515-281-5171. The medical board requires us to state the following:
  The practice of acupuncture in Iowa does not authorize a person to practice medicine and surgery in this state, and the services of an acupuncturist must not be regarded as diagnosis and treatment by a person licensed to practice medicine and must not be regarded as medical opinion or advice.
  All Practitioners are in full compliance with all regulations and rules promulgated by the Iowa Department of Public Health.
5. Elizabeth and William Terrell, L. Ac., MSOM practice acupuncture according to Traditional Chinese Medical (TCM)Theory. Please ask for your diagnosis and TCM medical references.
6. The iowa acupuncture clinic exclusively uses sterile, disposable, single use acupuncture needles.
7. If you have any questions, or concerns before, during or after your acupuncture, please call our clinic.
TCM acupuncture and herbal medicine clinic

initial TCM diagnostic visit. $40
acupuncture treatment. $85
return consultation. $25-85
adjunct acupuncture therapies. $5-25
couples/group acupuncture (per person). $70
I have read the above information and my signature endorses my understanding of the conditions.
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Clinic Information Form