New Patient Intake Form

I, the undersigned, certify that I (or my dependent) have insurance coverage with the insurance company named in this form and assign directly to JP Acupuncture & Wellness all insurance benefits, if any, otherwise payable to me for services rendered.

I understand that I am financially responsible for all charges whether or not they are paid by insurance, including any co-payment, deductible, co-insurance, or non-covered services. I authorize the use of my signature on all insurance submissions.

I authorize JP Acupuncture & Wellness to release all information necessary to secure the payment of benefits, and to release my medical information to my insurance company, referring provider, or other healthcare providers involved in my care as permitted by law.

I understand that I am responsible for payment at the time of service unless other arrangements have been made in advance, and I agree to notify the clinic of any change to my insurance coverage or contact information.

Consent to Treatment

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the licensed acupuncturist at JP Acupuncture & Wellness, and/or other licensed acupuncturists who now or in the future treat me while employed by, working with, or associated with JP Acupuncture & Wellness.

I understand that methods of treatment may include, but are not limited to: acupuncture, moxibustion (direct or indirect heat therapy), cupping, electrical stimulation, Tui Na (Chinese massage), therapeutic massage, Chinese herbal medicine, nutritional supplements, nutritional counseling, and essential oil therapy. I understand that I may ask about any treatment before it is performed and that I may decline any treatment at any time.

Risks and Possible Side Effects

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, minor bleeding, and dizziness or fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax); these risks are rare when treatment is performed by a licensed acupuncturist.

I understand that moxibustion and cupping may cause temporary redness, discoloration, or — rarely — burns or blistering of the skin, and that cupping commonly leaves temporary circular marks. Electrical stimulation may cause temporary muscle twitching or discomfort. I understand that Chinese herbal medicines and nutritional supplements may interact with prescription or over-the-counter medications, and I agree to inform my practitioner of all medications and supplements I am taking. I understand that some herbs may be inappropriate during pregnancy, and I will notify my practitioner immediately if I am or become pregnant.

I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist thinks, based on the facts then known, is in my best interest. I understand that acupuncture and Chinese medicine are not substitutes for conventional medical care, and that results cannot be guaranteed.

Acknowledgment

I have had an opportunity to discuss with my acupuncturist the nature and purpose of acupuncture treatment. By signing below, I consent to treatment and acknowledge that I have read, or have had read to me, the above consent. Questions I have asked have been answered to my satisfaction.