Authorization:
授权书:
I hereby authorize Choice Health Clinic to furnish medical records or other information concerning the treatment(s) to the respective insurance provider(sI will also assume full responsibility for any balance owed to Choice Health Clinic, not covered by my insurance provider.
本人授权中医诊所向保险公司提供本人的医疗及其他本人的疾病受伤记
录，并向保险公司索取本人应付的费用。本人有责任支付保险公司拒绝支付的所有费用。
Consent to Treatment:
本人同意接受：
I hereby acknowledge the common and normal reactions that may result from acupuncture, cupping, or moxibustion. Bleeding and bruising may occur on areas treated and I understand fully that these reactions are considered normal and expected and thus will not hold Choice Health Clinic liable.
中医诊所的中医针灸等治疗。并且不会因为针灸，推拿，拔罐，热敷等治疗所引起的出血，瘀血等正常反应向诊所提出诉讼。