Patient intake form

I understand that Acupuncture / Chinese Herbal Medicine, dietary therapy and other Traditional Chinese Medicine (TCM) modalities are safe and effective for the prevention and treatment of a wide range of health problems, and for the promotion of general well being. Although Acupuncture / TCM are helpful for many health conditions, I understand that it is not intended to replace any tests or treatments recommended by my physicians. I will continue to take my prescribed medications while I receive alternative treatment modalities at this clinic.

I have informed the TCM Practitioner (R.TCMP) / Acupuncturist (R.Ac) / Registered Nutritionist of all my known physical and emotional conditions, medical conditions and medications, and I will keep the Practitioner updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my forgetting to relay any pertinent information. I realize no claims, promises or guarantees are being made. I understand that medications and social habits may decrease the effects of alternative treatment modalities. I accept full responsibility for the effectiveness of my treatment.

I understand that Acupuncture and related TCM modalities are safe. Occasional bruising (which is normal skin reaction to needle insertion) may occur. Fainting is rare. However, it may happen due to extreme nervousness, hunger or fatigue. I also understand that herbal medicine are generally safe and effective. Occasional abdominal upset, diarrhea and sweating may occur in response to treatment.

The initial Appointment Fee for acupuncture / initial bioenergetic test / cupping or TCM Tuina Massage is $135 for all new patients; the Appointment fee for our food sensitivity test is $200 +tax. All fees are due at the time of service. 

The fees for Acupuncture are generally covered by your Private Health Insurance Program. I'll receive a receipt for service rendered and submit to my insurance company for health benefit claim. I understand that any amount not paid out by my insurance companies may be tax deductible.

A 2-business-day cancellation policy is in effect. Cancellation and rescheduling request with less than 2-business-day notice may result in a penalty fee of $50. This fee may be added to the subsequent appointment visit unless this is due to an emergency situation.

I will be on time for all my appointment bookings. If I arrive late for my appointment, I understand that I may not receive service due to time constraint. My appointment may be rescheduled to another day subject to my practitioner's availability.