THE BALANCED PATH WELLNESS CENTER ACUPUNCTURE INFORMED CONSENT
I understand that I am accepting treatment by a licensed, board-certified Acupuncturist, who graduated from a 2,150 hour Chinese Medicine Program. I am aware that a standardized clean-needle technique is used by The Balanced Path Wellness Center, including the use of sterile, disposable, one-time use needles. I understand that an Acupuncturist/Chinese Medical Practitioner is not a Medical Doctor, and thus, cannot perform Western Medical diagnoses, prescribe drugs, etc. Furthermore, if any of the following conditions exist without the present (or recent) attention from a Medical Doctor. I agree to seek Medical attention prior to being seen at The Balanced Path Wellness Center:
1) Cardiac Conditions 2) Acute Abdominal Pain 3) Unexplained Weight change in excess of 15% of body weight in past 3 mos. 4) Suspected Fracture or Dislocation 5) Suspected Infections 6) Acute Respiratory Problem with no prior history 7) Unexplained Bleeding I am aware that acupuncture contains risks that, although they are infrequent, are possible occurrences. The list contains, but is not limited to: localized pain/swelling, minor bruising, infection, dizziness/light-headedness, fainting. and broken needles. The Balanced Path Wellness Center is a cash practice. meaning that payment is received at the time of visit, by cash, check, Visa/MC or Paypal. Patients are responsible for contacting their insurance company for benefit information, and if coverage exists, for billing said insurance company. The Balanced Path Wellness Center will provide receipts upon request. The Balanced Path Wellness Center does not give refunds for any service or product (unless product is faulty A $99 fee (cash visit fee) is charged for all no-shows or cancellations within a 24 hour period. Insurance does NOT pay this. You will be responsible for paying this fee.