Your appointment time is reserved specifically for you. If you need to change or cancel your appointment, we request that you give us a minimum of 24 hours notice so we can offer the appointment time to someone else.

Please note that you will be charged for any appointments cancelled within 24 hours and insurance will not pay for the missed appointment.

I understand and agree that I am ultimately responsible for the balance on my account. I understand that all fees are payable at the time service is received.

If you purchase a treatment package of 10 sessions or more and wish to cancel your remaining sessions, a $50 administrative fee will be charged.

Keeping your medical history confidential is very important to us, and we strive to earn your trust by maintaining your privacy. If you would like a detailed outline of our policies, please refer to the Healing InSight Notice of Privacy Practices available in the clinic. Please ask for a Medical Records Release Restriction Form if you would like to request that no messages be left at your phone number or email, or if you would like to restrict specific individuals from accessing your medical records.

I acknowledge that I have received access to the Healing InSight Notice of Privacy Practices. I agree to the Healing InSight 24-Hour Cancellation Policy and Financial Policy.

I understand that I am the decision maker for my health care. Part of this office's role is to provide me with information to assist me in making informed choices. Acupuncture, Traditional Chinese Medicine (TCM), and functional medicine are not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncturists and functional medicine practitioners on me (or on the patient named below, for whom I am legally responsible) by practitioners employed at Healing InSight LLC.

Treatments types. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha, electrical stimulation, tui-na (Chinese massage), Chinese herbal medicine, functional medicine, lab testing, lifestyle counseling, and nutritional counseling.

Acupuncture. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types if healthcare interventions, there are some risks to care, including, but not limited to: bruising, bleeding, puffiness, itching, warmth pain; numbness or tingling near the needling sites that may last a few days; and dizziness or fainting. Burns, blistering and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include nerve damage, damage to deeper structures and organ puncture, including lung puncture (pneumothorax Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

Facial acupuncture. Facial acupuncture addresses the entire body constitutionally and is not merely "cosmetic". It involves the whole patient and is an organic, gradual process that is customized for each individual. It is not a substitute for a surgical facelift. An acupuncture facial does not arrest the aging process or produce permanent tightening of the face and neck. Future acupuncture maintenance treatments, or other treatments, may be necessary to maintain the results of an acupuncture facial. Risks are similar to those listed above and can include unsatisfactory results or in rare cases, asymmetry.

Herbs and supplements. The herbs, topicals and nutritional supplements (which are from plant, animal, chemical and mineral sources) that may be recommended are traditionally considered safe in the practice of Chinese Medicine and functional medicine, although some may be toxic in large doses. Some possible side effects of herbs, supplements or topicals are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; tingling of the tongue and allergic reactions. I will immediately notify my practitioner of any unpleasant effects associated with the use of herbs, supplements or topicals.

I understand I am under no obligation purchase herbs and supplements at this office. The chief reason we make these products available is to ensure quality. The same level of quality is not guaranteed when purchasing supplements from the general marketplace due to the lack of federal testing requirements for dietary supplements. The manufacturers we use have gained our confidence through considerable research and clinical experience.

Lab testing. The purpose of functional medicine laboratory testing is to evaluate nutritional, biochemical, or physiological imbalance to assist in finding the underlying causes of your condition; and to determine any need for medical referral. These lab tests are not intended to diagnose disease. This office utilizes conventional lab tests as well as functional medicine assessment. Healing InSight practitioners are not medical doctors and cannot act asa Primary Care Physician (PCP), SO I will continue my regular medical care and check-ups with my PCP and I will share the results of all lab tests with my primary care physician. Your PCP may or may not agree with the necessity for-or our interpretation of-these tests. If you have any questions or concerns, please discuss them with your practitioner at Healing InSight.

Medications. Healing InSight practitioners will not modify my prescription medication(s), which can only be done by my prescribing physician. If my underlying health has improved and I wish to change my medication or dosage then I will work with my medical doctor and follow their guidance.

Pregnancy. I understand that some herbs and supplements may be inappropriate during pregnancy. I will notify a clinical staff member who is caring for me if I am, or become pregnant, or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my prescribing practitioner and/or obstetrician.

Telemedicine. If I choose to utilize telemedicine, I understand that telemedicine consults typically involve the use of audio and/or video or other technology between me and the practitioner. Due to the nature of telemedicine, visits are largely educational and rely heavily on the patient history and laboratory findings. Exam and vital findings via video or phone are limited in nature vs an in-person examination.

Results. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.

Risks. I appreciate that it is not possible to consider every possible complication to care. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

Medical information. I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

I understand that there are treatment options available for my condition other than acupuncture procedures. I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

By voluntarily signing below, I confirm 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, functional medicine and other procedures, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. 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.