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Consent to Treat

I hereby request and consent to receiving acupuncture and/or massage therapy treatment from Jennifer Stevenson, L.Ac., CMT. I understand that methods of treatment may include, but are not limited to acupuncture, auricular therapy, moxibustion, cupping, guasha, electrical stimulation, tuina/massage, herbal medicine, and lifestyle counseling. I understand and am informed that although acupuncture is a safe method of treatment, there are some risks, including fainting, dizziness, nausea, bruising, infection, burns, pain, numbness and discomfort, pneumothorax, and aggravation of present symptoms. I am fully aware that the acupuncture needles are sterile and disposable and that no needle used on me has ever been used on another person. I understand that Oriental Medicine or massage is not a substitute for standard Western medical care, and I may seek Western medical advice and treatment at any time either instead of or concurrently with acupuncture or massage treatment. If I am currently pregnant or become pregnant, I will notify Jennifer Stevenson immediately. I understand that acupuncture treatment carries the possible risks of spontaneous miscarriage, and understand that not informing Jennifer in advance of treatment could cause risks to pregnancy. I understand that at any time during treatment I have the opportunity to discuss questions regarding the nature and purpose of acupuncture and Oriental Medicine along with the potential risks of treatment. I understand that although acupuncture and Oriental Medicine have benefited millions of people over thousands of years, no guarantee of cure or improvement in my condition is given or implied. In the event of receiving massage therapy, I understand the basic purpose is relaxation and relief of muscle tension and pain. If I experience any pain or discomfort during this and any following sessions, I will immediately inform Jennifer so that the pressure and/or strokes can be adjusted to my level of comfort. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in the termination of the session and I will be liable for the payment of the session.

Privacy of Health Information


I understand that as part of my healthcare, Jade Spring Acupuncture & Massage originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among any healthcare professionals who may contribute to my care. A source of information for applying my diagnosis information to my bill. A means by which a third-party payer can verify that services billed were provided. I understand that I have the right to: Request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. Revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon.

Mandatory Disclosure
Jennifer Stevenson attended the Colorado School of Traditional Chinese Medicine and earned a Masters of Science in Acupuncture and Chinese Herbal Medicine after completing the schools 2850 hours of training. She is Board certified as a Diplomat of both Acupuncture and Chinese Herbal Medicine by the National Certification Commission for Acupuncture and Chinese Medicine (certificate number 151579), and holds a Colorado acupuncture license issued by the Department of Regulatory Agencies (DORA) (license number 1791). Additionally, Jennifer obtained her massage training at the Advanced Fuller School of Massage Therapy in Virginia Beach, VA in a 615 hour program and is certified by the National Certification Board for Therapeutic Massage & Bodywork to practice massage therapy (license number 502278-05). She holds a Colorado license issued by DORA (license number 7443). Jennifer is a member of the Acupuncture Association of Colorado and the American Acupuncture Council, and none of her licenses have ever been revoked. Jade Spring Acupuncture & Massage complies with all rules and regulations laid down by the Colorado Department of Public Health and Environment, including sanitation of clinic rooms and sterilization of all equipment used during treatment. Only single-use, factorysterilized needles are used and safely disposed after each treatment. Fees will be charged as follows: Initial evaluation and consultation: free Acupuncture treatment: $60 + cost of herbs Herbal consult without acupuncture: $40 plus cost of herbs. 60 minutes of massage therapy: $55-65 depending on type of massage requested 90 minutes of massage therapy: $70-80 depending on type of massage requested The patient is hereby advised that they are entitled to receive information about the methods of therapy, the techniques used and the duration of therapy (if known). Also they are free to seek a second opinion and may terminate therapy at any time. In a professional relationship, sexual intimacy or advances are never appropriate and should be reported to the Director of the Division of Registrations at DORA. They may be contacted at: 1560 Broadway, Suite 1350, Denver, CO 80202. Telephone 303-894-7800.

Office Policies
I understand that Jade Spring Acupuncture & Massage will use my email address to confirm appointments and send a monthly newsletter. Further, I understand that the organization will never sell my contact information, or spam my email account and that at any time I have the right to request to be taken off of the organizations mailing list. I have been notified that Jade Spring Acupuncture & Massage has a 24 hour cancellation policy. In the event that I miss an appointment without notifying Jennifer Stevenson, or cancel without due notice, I may be charged 40% of the cost of the scheduled appointment. Initial:

I have read & understand this document.

Patient or Guardian Name

Signature

Date

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