I hereby request and consent to the performance, now and in the future of the following on me, or on the patient named below for whom I am legally responsible, by Dr. Glenn Wilcox, D.O.M., M.Sc.

• Acupuncture and other oriental medicine procedures including diagnostic techniques such as questioning, pulse evaluation, manual palpation performed on a variety of areas of my body, range of motion evaluation, muscle, orthopedic and neurological testing.
• Various physical medicine modalities and therapeutic procedures such as massage, manipulation of joints and body structures, heat and cold therapy, electrical or magnetic stimulation and acoustic wave therapy (also called shockwave or GainsWave).
  
  
• The recommendation or prescription of herbal and homeopathic medicines as well as dietary or nutritional supplements and other natural health care products and devices, and dietary recommendations.
  
  
• Advice regarding exercise regimens; lifestyle counseling.
  
  
• Oriental medicine expanded practice and prescriptive authority procedures and prescriptions for which I understand Dr. Wilcox is certified by the New Mexico Board of Acupuncture and Oriental Medicine. These include injection therapies, intravenous therapies, and bioidentical hormone therapies.

I understand that there are some risks associated with oriental medical treatment and that while unlikely, possible risks that have occurred because of treatment by Dr. Wilcox include: an occasional bruises, hematoma or spot of blood, general aches, and with some conditions a temporary aggravation of symptoms, and new symptoms. However, even though the following have not occurred from treatment by Dr. Wilcox, other possible risks include but are not limited to: bleeding, inflammation, infections, burns, sprains, strains, nerve pain, dislocations, fractures, disc injuries, strokes, and puncture of organs. I also understand that while very unlikely, it is theoretically possible for death to occur because of treatment.

I do not expect the doctor to be able to anticipate and explain all risks and complications during treatment. I wish to rely on the doctor’s judgment based on the facts known at the time. Regarding acupuncture treatment, I understand that generally I should experience no pain or discomfort. However, some vigorous needle manipulation techniques may cause a variety of sensations, that may be somewhat painful at times for some people. These sensations may occur at the location where a needle is inserted or may radiate from that location. If Dr. Wilcox plans to use such techniques on me, I understand that he will discuss this with me first and that I will have the option to decline. I also understand that the acupuncture needles used are FDA approved, single use, sterilized and properly disposed of after each use. Regarding injection therapies, intravenous therapies, and bioidentical hormone therapies, I understand that Dr. Wilcox will discuss these in detail with me if they are a treatment option. Regarding diagnostic testing and imaging, I understand that Dr. Wilcox will discuss these in detail with me if they are a diagnostic option

Outstanding Balances

• Outstanding balances must be paid in full before additional appointments may be scheduled.
• Payments are applied first to any unpaid balances.
• A $35.00 fee applies to any returned checks. Afterward, only cash, money order, or major credit cards will be accepted.

Authorization to Release Information
I authorize the release of medical or other necessary information to my insurance carrier(s) or related entities for the purpose of determining benefits or processing claims. This will only occur upon request of the patient. This agreement will be kept on file by Dr. Glenn Wilcox.

Payment Agreement
I have read, understand, and agree to the above payment policies and authorize the release of information as stated.