• Informed Consent for Treatment

    Please read each section carefully and provide your signature at the end to confirm your consent.

  • BEFORE YOU BEGIN
    Read each section below carefully. Ask your practitioner any questions before signing. Your signature at the end of this document confirms you have read and agree to this and all other forms below.

    PURPOSE OF TREATMENT
    The goal of acupuncture is to promote healing, reduce pain, and restore function using the principles of Traditional Chinese Medicine (TCM). TCM diagnosis does not replace Western medical evaluation or treatment.

    ACUPUNCTURE & ELECTRO-ACUPUNCTURE
    Acupuncture uses thin filiform needles inserted at specific body points to normalize function and modify pain. Needle location and depth are determined by your clinical presentation. Treatment is performed in accordance with the methods and safety standards required by the California Acupuncture Board, the State licensing agency. A sterile, single-use filiform acupuncture needle will be inserted into each point using the methods and safety standards required by the California Acupuncture Board. Electro-acupuncture adds gentle electrical stimulation to enhance therapeutic effect. Possible side effects: brief discomfort, minor bruising, swelling, or skin discoloration. Rare risks include dizziness, fainting, or pneumothorax (partial lung collapse).

    MOXIBUSTION
    Heat is applied directly or indirectly using the herb Artemisia vulgaris over acupuncture points. The treated area may remain warm and red for several hours. Minor burns are a rare possibility.

    CUPPING
    Vacuum cups applied to muscular areas to stimulate circulation. Temporary redness, discoloration, or bruising lasting up to one week is common and expected — these marks are not injury. Minor blistering is rare.

    GUA SHA
    A smooth tool is used to scrape the skin surface, producing temporary bruising to stimulate circulation. Minor skin indentation or surface bleeding may occur. If bleeding occurs, a small risk of infection exists.

    ACUPRESSURE & TUI NA
    Manual therapy to normalize physiologic function and reduce pain. Possible side effects: bruising, temporary muscle soreness, or brief aggravation of pre-existing symptoms before improvement.

    INFRARED & TDP LAMP THERAPY
    Therapeutic heat applied via an adjustable lamp above the treatment area. Risk of burn if the lamp contacts the skin; your practitioner will monitor positioning throughout treatment.

    HERBS & NUTRITIONAL SUPPLEMENTS
    Herbal formulas may be recommended to support treatment. Herbs are generally safe within TCM dosing guidelines but may interact with medications, be contraindicated in pregnancy, or cause reactions including nausea, digestive upset, or rash. Herbs are optional. If taken, follow all dosing instructions and notify your practitioner of any adverse effects. Topical preparations may occasionally cause skin irritation.

    CONTRAINDICATIONS & DISCLOSURES
    Notify your practitioner if you have: a bleeding disorder or are on anticoagulant therapy, an implanted pacemaker or prosthetic heart valve, are pregnant or trying to conceive, or take medications that may interact with treatment. I confirm my medical history as provided is complete and accurate, and I will report any changes.

    PRIVACY & CHAPERONE RIGHTS
    Some treatments may require partial disrobing. You have the right to request a chaperone at any time. Your privacy and comfort are a priority throughout treatment.

    GENERAL CONSENT
    I understand that: no treatment outcome is guaranteed; symptoms may temporarily worsen before improving; not all risks can be anticipated; and my practitioner will exercise sound clinical judgment throughout my care. I may withdraw consent and stop treatment at any time without penalty.

    PATIENT SIGNATURE 
    By signing below, you confirm that you have read, understood, and agree to the Informed Consent, Telehealth & Messaging, Cancellation Policy, Release of Information, and HIPAA Acknowledgment sections above.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Anchor Point Acupuncture

    624 Frederick Street, Santa Cruz, CA 95062 |Ph: 831-515-6049|Fax: 831-400-3345 

    Tiffany Tuftee, L.Ac., Dipl. O.M., QME

  • Telehealth and Secure Messaging Consent

  • TELEHEALTH & SECURE MESSAGING
    Anchor Point Acupuncture offers telehealth consultations for follow-up care, herbal review, and case management. Please read each section below.

    TELEHEALTH SERVICES
    Nature of telehealth: Sessions are conducted via secure video or audio platforms. I understand telehealth has inherent limitations — including no physical exam — and that my practitioner will determine when in-person care is required.
    Technical limitations: Connectivity issues may occasionally interrupt sessions. My practitioner is not responsible for technology failures, and an alternative appointment will be offered if a session cannot be completed.
    Emergencies: Telehealth and Signal are not for emergencies. In a medical emergency, call 911 immediately. I will not use any messaging platform to report urgent or life-threatening symptoms.

    SECURE MESSAGING VIA SIGNAL
    Signal as a communication channel: Anchor Point Acupuncture uses Signal — an end-to-end encrypted app — for scheduling, care coordination, herbal follow-up, and general communication between visits.
    Limitations: Signal is not continuously monitored; responses are subject to office hours and are not guaranteed. It is not a substitute for a scheduled appointment. Phone and fax are always available as alternatives.
    Voluntary participation: Telehealth and Signal communication are optional. I may withdraw this consent in writing at any time without affecting my right to in-person care.

     

     

  • Anchor Point Acupuncture

    624 Frederick Street, Santa Cruz, CA 95062 |Ph: 831-515-6049|Fax: 831-400-3345 

    Tiffany Tuftee, L.Ac., Dipl. O.M., QME

  • Cancellation Policy

  • CANCELLATION & LATE ARRIVAL POLICY
    Your appointment time is reserved exclusively for you. Please read each section below.

    CANCELLATION NOTICE
    24-hour notice required. If you need to cancel or reschedule, please notify Anchor Point Acupuncture at least 24 hours before your scheduled appointment. Cancellations may be made by phone at 831-515-6049.

    LATE CANCELLATION FEE
    Cancellations made less than 24 hours before your appointment will be subject to a late cancellation fee of $75. This fee is not billable to insurance and is the sole responsibility of the patient.

    NO-SHOW POLICY
    Failure to appear for a scheduled appointment without prior notice constitutes a no-show and will result in a fee of $100. Repeated no-shows may result in discharge from care.

    LATE ARRIVAL
    If you arrive late, your session will end at the scheduled time out of respect for other patients. Arriving more than 15 minutes late may result in your appointment being treated as a no-show at the practitioner's discretion.

    ATTENDANCE & TREATMENT CONTINUITY
    Consistent attendance supports the best treatment outcomes. Missed appointments may affect the continuity and effectiveness of your care plan. It is your responsibility to attend all scheduled visits and communicate any scheduling conflicts to this office as far in advance as possible.

    EMERGENCIES & EXCEPTIONS
    We understand that emergencies happen. Fees may be waived at the practitioner's discretion for documented emergencies or acute illness. Please contact us as soon as possible if an unexpected situation arises.

    PATIENT SIGNATURE: 
    By signing below, you confirm that you have read, understood, and agree to the Informed Consent, Telehealth & Messaging, Cancellation Policy, Release of Information, and HIPAA Acknowledgment sections above.

  • Anchor Point Acupuncture

    624 Frederick Street, Santa Cruz, CA 95062 |Ph: 831-515-6049|Fax: 831-400-3345 

    Tiffany Tuftee, L.Ac., Dipl. O.M., QME

  • AUTHORIZATION TO RELEASE & EXCHANGE MEDICAL INFORMATION

    This form authorizes Anchor Point Acupuncture to communicate with and exchange records with your treating providers, insurance carriers, and other authorized parties as needed for your care and case management.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • AUTHORIZATION TO SPEAK WITH & EXCHANGE RECORDS

    Treating providers: I authorize Anchor Point Acupuncture to communicate with and exchange medical records, treatment notes, reports, and relevant clinical information with my treating physicians, specialists, physical therapists, chiropractors, and any other licensed healthcare providers involved in my care.

    Insurance & payers: I authorize the release of medical records, progress notes, reports, billing records, and treatment plans to my health insurance carrier or other authorized third-party payer involved in covering my care.

    Legal representatives: I authorize communication with my attorney or legal representative, if applicable, regarding my medical care, treatment history, and clinical progress as it pertains to my case.

    SCOPE & LIMITATIONS

    I understand that: (1) This authorization covers only information relevant to my current condition and treatment at Anchor Point Acupuncture; (2) I have the right to revoke this authorization at any time in writing, except where disclosure has already occurred; (3) Revocation does not affect prior disclosures made in good faith; (4) My treatment will not be conditioned on signing this form, except where authorized by law.

    I understand that once records are released to a third party, Anchor Point Acupuncture cannot control further use or disclosure by that party. This authorization expires one year from the date of signature unless revoked earlier in writing.

    SPECIFIC PROVIDERS AUTHORIZED (OPTIONAL)

  • Anchor Point Acupuncture

    624 Frederick Street, Santa Cruz, CA 95062 |Ph: 831-515-6049|Fax: 831-400-3345 

    Tiffany Tuftee, L.Ac., Dipl. O.M., QME

  • HIPAA Notice of Privacy Practices — Acknowledgment

    Please read each section below.

  • Federal law (HIPAA) requires that you be offered a copy of our Notice of Privacy Practices, which describes how your health information may be used and disclosed. Please read each section below.

    RECEIPT OF NOTICE
    My signature confirms that I will receive a copy of Anchor Point Acupuncture's Notice of Privacy Practices at my initial in-person intake. This Notice describes how my protected health information (PHI) may be used and disclosed, and it will be available for my review at my first visit.

    USE & DISCLOSURE OF HEALTH INFORMATION
    I understand that Anchor Point Acupuncture may use and disclose my PHI for purposes of treatment, payment, and healthcare operations (TPO) — including coordinating care with other providers, billing insurance, and internal quality and administrative activities — without additional written authorization.

    MY RIGHTS
    I understand I have the right to: request access to and copies of my records; request amendments to my records; request an accounting of certain disclosures; request restrictions on certain uses and disclosures; request confidential communications by alternate means; and file a complaint with this office or the U.S. Department of Health & Human Services if I believe my privacy rights have been violated, without fear of retaliation.

    ACKNOWLEDGMENT
    I understand that this acknowledgment does not itself authorize any specific disclosure of my PHI, and that Anchor Point Acupuncture's Notice of Privacy Practices may be updated from time to time, with the current version available upon request at the office.

    PATIENT SIGNATURE 
    By signing below, you confirm that you have read, understood, and agree to the Informed Consent, Telehealth & Messaging, Cancellation Policy, Release of Information, and HIPAA Acknowledgment sections above.

  • Anchor Point Acupuncture

    624 Frederick Street, Santa Cruz, CA 95062 |Ph: 831-515-6049|Fax: 831-400-3345 

    Tiffany Tuftee, L.Ac., Dipl. O.M., QME

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