PLEASE READ CAREFULLY BEFORE SIGNING

TREATMENT CONSENT, RISKS & ACKNOWLEDGEMENT

01    I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture, as necessary, including cupping, taping, magnet, acupressure and/or electro acupuncture by the licensed acupuncturist in the clinic.

02    I understand and am informed that in the practice of acupuncture there are some risks to treatment, including, but not limited to, minor bleeding or bruising, minor pain or soreness, swollen, redness and red marks (cupping) tingling, numbness, nausea, infection, fainting, shock, convulsions, possible puncture of internal organs, and stuck or bent needles.

03    I have been advised that only pre-sterilized needles will be used. All acupuncture needles are properly disposed of after each and every treatment. I do not expect the doctor to be able to anticipate and explain all possible risks and complications.

04    I wish to rely on the doctor to exercise judgment during the course of the treatment which the doctor feels at the time, based upon the facts the known, is in my best interests. I understand that the results are not guaranteed. I have read the above consent form. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above mentioned acupuncture procedures.

SPECIAL TREATMENT CONSIDERATIONS

05    We can refuse to provide acupuncture treatment to anyone under influence of alcohol, drugs, substance, unsanitary condition and HTN over 160.

06    Female patients: I fully understand that in the case of pregnancy, a risk of causing fetal distress with acupuncture treatment(s) is possible. I hereby state that I am not pregnant, nor is there any possibility that I may be pregnant.

PATIENT RESPONSIBILITIES

07    I understand that I am responsible for providing accurate health information, informing the clinic of changes that may affect treatment, following treatment instructions, and attending scheduled appointments or notifying the clinic when I need to cancel or reschedule.

08    I understand that if KCS is not my assigned Managed Medi-Cal Primary Care Provider (PCP), KCS providers cannot make internal referrals, and I am not eligible for ongoing KCS primary care or specialty services, including but not limited to CAM services.

ATTENDANCE, LATE ARRIVAL & CANCELLATION POLICY

09    Late Arrival: I understand that if I arrive 10–20 minutes late for my scheduled appointment and still wish to receive treatment, I may receive treatment for the remaining scheduled appointment time. I understand and agree that my treatment time will be shortened and the appointment will not be extended.

10    Cancellation/Rescheduling: I understand that I am required to provide at least 24 hours advance notice when cancelling or rescheduling an appointment. Cancellations made with less than 24 hours notice or missed appointments (no-shows) will be subject to the clinic’s cancellation and attendance policy.

11    Repeated No-Shows: I understand that 3 consecutive no-shows or 3 no-shows within a 6-month period may affect my ability to schedule CAM services and may result in a temporary suspension of routine CAM treatment in accordance with clinic policy.

ARBITRATION

Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decide in court of law before jury and instead are accepting the use of arbitration. Further the parties will not have the right to participate as a member of any class of claimants, and there shall no authority for any dispute to be decided on a class action basis. Any arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims. By signing this contract, I am agreeing to have any issue of medical malpractice decided by neutral arbitration, and I am giving up my right to jury or court trial. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

I intend this consent to apply to all my present and future acupuncture treatment.