Client services and chart information are confidential. Written authorization is required from you to release any information.
• Please turn off your mobile phone for optimal relaxation
• Your scheduled session is set aside for you. We do not double book appointments
• Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee of 50%. Less than 24 hours notice will incur a cancellation fee of 50% of the scheduled fee
• You will have a consultation with your practitioner to discuss your session
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.
I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Melissa Durfey Skin and Wellness and my practitioner from any liability whatsoever arising from failure on my part.
Informed Consent to Treatment:
I hereby agree and consent to the performance of Traditional Chinese and Japanese Medicine procedures. I understand that such procedures may include, but are not limited to, acupressure, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In (Japanese massage), Shiatsu (Japanese massage), Chinese or western herbal medicine, lifestyle, exercise and nutritional counselling.
Acupressure is the application of pressure to specific points on the body. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Tui Na (Chinese massage), Reflexology, Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment.
I have been informed that East Asian Medicine is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, and/or minor swelling. A sensation of light-headedness may occur after treatment. I will immediately notify the my practitioner if I experience any symptoms or problems. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform my practitioner if the moxibustion feels at all uncomfortable.
I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that Chinese and Japanese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan.
This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases allergic skin reactions to massage oils, acupressure devices, or topical applications are a possibility.
I will inform my practitioners immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *