Patient Consent And Authorization
By signing below, I acknowledge, agree, and authorize the following:
a) Accurate Information:
The information I have provided is accurate, complete, and current to the best of my knowledge.
b) Patient Rights and Responsibilities:
I am aware of the facility’s Notice of Privacy Practices, which explains the use and disclosure of my protected health information. I understand my rights to access my health records and have had the opportunity to review the Notice of Privacy Practices before signing.
c) Release of Medical Information:
I authorize the release of my health information as described in the Notice of Privacy Practices, including to my referring and primary care physicians and any subsequent specialists. This facility complies with HIPAA regulations to maintain the confidentiality of my health information.
d) Consent to Communication:
I consent to receive appointment reminders, scheduling confirmations, and test results via phone, email, or other communication channels.
e) Comprehensive Authorization:
I authorize the facility to access, use, and disclose my medical history for treatment, insurance processing, or procedure authorization.
f) Appointment Policy Acknowledgment:
I understand and agree to the following policies:
Deposits: Non-refundable and non-transferable; applied to session costs.
Insurance Patients: If the copay is less than the deposit, the difference is refunded or credited.
Personal Injury & Workers' Compensation Patients: A deposit is required and applied to session fees. If canceled or rescheduled per policy, it may be refunded or credited.
24-Hour Notice: Cancellations or rescheduling require at least 24 hours' notice.
Late cancellations incur a fee: $50 for PI, WC, and Insurance patients. 50% of session fee for all others
Rescheduling: One reschedule per deposit. Additional reschedules require a new deposit.
Late Arrivals (15+ min): $50 fee for PI, WC, and Insurance patients 50% of session fee for others
No-Shows: $50 fee for PI, WC, and Insurance patients 50% of session fee for others
May result in loss of future booking privileges.
I acknowledge that these policies ensure fair access for all patients
I understand that acupuncture is not a substitute for medical diagnosis or treatment and should not replace necessary medical care. I should be under the care of a physician as needed. Pregnant patients must be managed by an appropriate provider, and cancer patients should be under an oncologist's care.
I consent to treatment by a licensed acupuncturist, including but not limited to acupuncture, electro-acupuncture, moxibustion, cupping therapy, gua sha, manual therapy, infrared therapy, knife needle therapy (acupotomy), micro-needling, cosmetic acupuncture, ear seeds therapy, herbal medicine, and nutrition guidance. Knife needle therapy may cause bruising or mild swelling.
I acknowledge the potential risks and side effects, including mild bruising, soreness, or tingling at treatment sites, dizziness or fainting during or after treatment, burns or skin irritation from moxibustion or heat lamps, temporary skin discoloration from cupping or gua sha, and rare risks such as infection, nerve damage, or lung puncture (pneumothorax).
I understand that herbal medicine and supplements may cause nausea, diarrhea, headaches, allergic reactions, or other side effects. Pregnant or nursing patients must inform the practitioner before taking herbs. Some herbs may interact with medications, and I am responsible for disclosing all prescriptions. Due to the nature of herbal prescriptions, refunds or exchanges are not allowed.
I acknowledge that my health records are confidential and will not be released without consent. I must provide accurate health history, including medications, for safe treatment.
I am aware that alternative treatment options exist, including self-care, rest, over-the-counter medication, physical therapy, chiropractic care, injections, or surgery.
By signing below, I confirm that I have read and understood this consent form, have been informed of the risks and benefits, have had an opportunity to ask questions, and voluntarily agree to receive acupuncture and related therapies. I intend this consent to apply to all current and future treatments.
At Provision Acupuncture, we love sharing success stories and educational content to inspire our community. We occasionally take photos or videos during treatment sessions to share on social media and show the benefits of acupuncture. Sharing these moments helps others see the positive impact of natural healing and supports our community. Follow us on Instagram: @provision_acu
By signing this form, I hereby grant Provision Acupuncture the right to capture photographs and/or video of me during my treatment sessions and to use these images and videos for social media and other marketing purposes. I understand that the content may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.
This consent includes the use of said media on platforms such as Instagram, YouTube, and the clinic’s website. The consent is continuous without an expiration date, unless explicitly revoked in writing. I am aware that I will not be identified by name in any posts unless I provide specific consent to do so. I understand that I may revoke this consent at any time by submitting a written notice to the clinic, effective upon receipt.
