New Client Form

The following questions relate to your current and previous health condition and will take less than 10 minutes to complete. Please ensure you complete all the fields marked with an asterisk *.

All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *.

Client Medical History

Please complete the following questionnaire to the best of your knowledge. Further questions may be asked by your practitioner regarding the information provided here.

Please check any symptoms that apply to you and use the Other category to add symptoms not listed.

Clinic Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.  

• Please turn off your mobile phone for optimal relaxation      

• Your scheduled session is set aside for you. We do not double book appointments      

• Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee 80%. Less than 24 hours notice will incur a cancellation fee of 100% of the scheduled fee       

• You will have a consultation with your practitioner to discuss your session

Client Agreement:

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Integrative Health Chinese Medicine Centre and my practitioner from any liability whatsoever arising from failure on my part.

Informed Consent to Treatment:

I hereby agree and consent to the performance of acupuncture and other Traditional Chinese and Japanese Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In (Japanese massage), Shiatsu (Japanese massage), Chinese or western herbal medicine, lifestyle, exercise and nutritional counselling.

Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Tui Na (Chinese massage), Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment.

I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable.

I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Chinese and Japanese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan.

This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections or collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility.

I will inform my practitioners : Stefanie Rothert, Lieum Fallon, Mic Leese, Deena Ball, immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *

Mandatory Disclosure Form: Stefanie Rothert LAc. L.M.T. 

7595 66th ave arvada, co 80003

1800 30th St. Suite 309 Boulder, CO 80301

Masters of Science in Oriental Medicine Herbology. This is a 3045 hour program including 1140 hours of clinical experience. Completed in December of 2009. Southwest Acupuncture College, Boulder, Co. Pacific College of Oriental Medicine, San Diego, CA.
: Includes the study of Acupuncture and Chinese

Nationally Certified in Acupuncture. : Medicine. August 2009.

National Certification for Acupuncture and Oriental

Certificate of Massage Therapy:
The Connecting Point School of Massage Therapy. Telluride,

Nationally Certified in Massage Therapy: Completed and maintained since November 2002. Stefanie is licensed in the state of Colorado. These certificate or licenses have never been revoked. Her practice includes the modalities; various styles of Massage, Acupuncture, Chinese Herbology, Gua sha, Cupping and Moxibustion. This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning, disposal and sanitation of needles and sanitary practices of acupuncture offices. Only single use, factory sterilized, and disposable needles are used. Patient’s rights:
The patient has the right to receive information about all of the therapeutic techniques used, if known.
The patient is entitled to get a second opinion from another healthcare professional or to terminate treatment at any time.
In a professional relationship, sexual intimacy is never appropriate, and should be reported immediately to the Director of Registrations in the department of regulatory agencies.
Stefanie’s training and experience in the recommendation and application of adjunctive therapies and Herbs as defined by Traditional Medical Concepts. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, please contact the Acupuncturists Registration Office, 1560 Broadway Suite 1350, Denver, Co, 80202. (303) 894 2440.

Liability Waiver:

I hereby consent to acupuncture treatments and related procedures associated with Oriental Medicine & Massage Therapy, Stefanie Rothert, L.Ac., Lieum Fallon LAc, Mic Leese & Deena Ball.  I understand that the methods of treatment may include but are not limited to either acupuncture or massage therapy (which ever Treatment I recquested), facial acupuncture, moxabustion, cupping, gua sha, Tui-Na, electrical stimulation, Chinese herbology,  shoni shin and nutritional counseling. If I am here for pre-natal massage or acupuncture, I forfeit any liabilty to the practitioners. 
I have been informed that acupuncture and massage are safe method of treatment, however it may have minor side effects, including bruising, numbness or tingling near the needling sites which may last a few days, and in rare cases, dizziness or fainting. This facility only uses sterile, disposable needles and maintains a clean and safe environment. Burns and scarring are potential risks of moxabustion. Bruising is a common side effect of cupping and gua sha treatment, and may last a few days to a week. Although rare and uncommon, there have been cases reported of nerve damage, organ puncture, including lung puncture (pneumothorax) and spontaneous miscarriages. I understand that sometimes Acupuncture may cause dizziness, and/or more severe reactions, and I will not hold the acupuncturist liable for any illness, or even death.  I understand that while this document describes the major risks of treatment, other side effects and risks may occur, and I agree to hold not fault to the Practitioner. 

I understand If I receive Massage that I may be sore, or rarely have bruises. 

I understand that there are some acupuncture points and chinese herbs that are inappropriate during pregnancy. I will notify the acupuncturist should I become pregnant or if I am trying to become pregnant.

The herbs and nutritional supplements (which are from plant, mineral, and animal sources) that are used are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. If I experience any gastrointestinal upset, headache, rashes or allergic reactions or any unpleasant side effects from the herbs I will stop taking them and immediately inform the acupuncturist.

I do not expect the acupuncturist/ massage therapist to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the acupuncturist/ massage therapist to exercise judgment during the course of treatment, and decide what she thinks is in my best interest, based upon the facts that are known at the time. I understand the practitioner and administrative staff may review my medical records and reports, but all of my records will be kept confidential and will not be released without my written consent or official court subpoena.

By voluntarily signing below, I show that I have read and understand this consent to treatment and that I have read and understand the Colorado Mandatory Disclosure form. I have been informed about the risks and benefits of acupuncture and other procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. I forfeit all liability for any Treatment I have received at Acupuncture for Wellbeing/ Arvada Massage Therapy/ Boulder Massage With Deena with Stefanie Rothert, Deena Ball, Mic Leese or Lieum Fallon

Mandatory Disclosure Form: Lieum McNeil Fallon LAc.
Acupuncture for Wellbeing: 7595 W 66th Ave, Arvada, CO 80003
Live Fit Acupuncture: 7154 Eldridge Court, Arvada, CO 80004
Colorado Acupuncture License # 1680
Education and Experience: Masters of Science in Oriental Medicine: Includes the study of
Acupuncture and Chinese Herbology. This is a 3045 hour program including 1140 hours of
clinical experience. Completed in December of 2008. Pacific College of Oriental Medicine, San
Diego, CA.
Nationally Certified in Acupuncture. : National Certification for Acupuncture and Oriental
Medicine February 2011.
Lieum is licensed in the state of Colorado.
These certificate or licenses have never been revoked. Her practice includes the modalities;
various styles of Massage, Acupuncture, Chinese Herbology, Gua sha, Cupping and
Moxibustion. This clinic complies with the rules and regulations promulgated by the Colorado
Department of Health, including the proper cleaning, disposal and sanitation of needles and
sanitary practices of acupuncture offices.
Only single use, factory sterilized, and disposable needles are used.
Patient’s rights:
The patient has the right to receive information about all of the therapeutic techniques used, if
known.
The patient is entitled to get a second opinion from another healthcare professional or to
terminate treatment at any time.
In a professional relationship, sexual intimacy is never appropriate, and should be reported
immediately to the Director of Registrations in the department of regulatory agencies.
Lieum’s training and experience in the recommendation and application of adjunctive
therapies and Herbs as defined by Traditional Medical Concepts. The practice of acupuncture is
regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you
have comments, questions, or complaints, please contact the Acupuncturists Registration Office,
1560 Broadway Suite 1350, Denver, Co, 80202. (303) 894- 2440.