Please List Any Medication You Are Taking
Current health habits and symtoms:
I understand that Acupuncture / Chinese Herbal Medicine, dietary and nutritional 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 / Dietary and Nutritional Supplementation is 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 / cupping or TCM Tuina Massage is $120 (special promotion price) for all new patients.
The initial bioenergetic test is $135 +Tax for all new patients.
The Appointment fee for food compatibility test, Pregnancy Success Preparation Session and Cancer Recovery Planning Session is $200 +tax each.
The consultation fee for Chinese herbal medicine is $80 + Tax. Chinese herbs can be purchased at cost plus shipping and administration fees. There is no refilling fee unless a new assessment, diagnosis and herbal medicine prescription are required. The fee is $35 + tax.
If you are here for an acupuncture treatment or Chinese herbal medicine prescription and subsequently request nutritional advice to improve your health condition, please note that a discounted nutritional consultation fee of $35 + Tax may be added to your invoice (the regular fee is $80 + Tax).
Your Private Health Insurance Program generally covers the fees for Acupuncture and nutritional consultation. You may want to also check if you have a "Health Care Spending Account" with your insurance to cover any service fees. You'll receive a receipt for the service rendered.
To cover my business expenses, if you cancel or request to reschedule with less than 2 business days' notice or miss your appointment, a fee of $50 will apply to your subsequent appointment visit unless this is due to a MEDICAL emergency. If you expect to see a doctor, please reschedule your appointment well in advance.
Please be on time for all your appointment bookings. If you arrive late for your appointment, and you receive services, you will still be responsible for the full appointment fee.
Please be on time for all your appointment bookings. If you arrive late for your appointment, and you could not receive service due to time constraints, a fee of $50 will apply to your subsequent visit unless it was due to a MEDICAL emergency.
