Informed Consent to Treat 

Acupuncture: I voluntarily consent to participate in Acupuncture treatment. I fully understand that Acupuncture is not a substitute for medical emergencies. I am aware that Acupuncture involves the insertion of disposable needles into the body to treat bodily dysfunction or diseases, modify or prevent pain perception, and normalize the body's physiological functions. Certain side effects may occur, such as local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing before acupuncture treatment. There are no guarantees concerning its use and effects, and you are free to stop acupuncture treatment at any time. 

Moxibustion/Heat Lamps: I understand that the treatment might include the application of heat to the skin. 

Acupressure/TuiNa Massage/Cupping: I understand that I may also be given acupressure/tuina massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result, these may include but are not limited to bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior before treatment. I understand that I may stop the treatment if it is too uncomfortable. 

Injection Therapy: I understand that I may be given an injection of an herb, homeopathic, or vitamin, and, as with all injections, it may cause pain, or redness at the site of injection, though this is rare. 

Chinese Herbs/supplements: Chinese herbs and supplements from the Oriental Materia Medica may be recommended to you to treat bodily dysfunction or diseases, modify or prevent pain perception, and normalize the body's physiological functions. I understand that I am not required to take these substances, but if I do, I must follow the directions for administration and dosage. Certain side effects may occur, such as changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing before herbal treatment. If you experience any problems associated with these substances, please suspend taking them and call the Clinic as soon as possible. 

I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.

HIPAA Notice of Privacy Practices

This notice explains how we may use and disclose your protected health information (PHI) and how you can get access to this information. Please review this notice carefully.

What is PHI?

PHI is any information that can be used to identify you and that relates to your past, present, or future physical or mental health condition, the provision of health care to you, or the payment for your health care. Examples of PHI include your name, address, date of birth, Social Security number, medical records, and billing information.

How do we use and disclose your PHI?

We use and disclose your PHI to provide you with acupuncture care, to obtain payment for your care, and for other healthcare-related purposes. For example, we may use your PHI to:

• Schedule appointments
• Provide acupuncture treatments
• Refer you to other healthcare providers
• Bill your insurance company
• Conduct research

We may also disclose your PHI to other entities without your written consent for certain limited purposes, such as:

• To report suspected abuse or neglect
• To comply with a court order or subpoena
• To prevent or lessen a serious and imminent threat to your health or safety or the health or safety of another person

What are your rights under HIPAA?

You have the right to:

• Access your PHI
• Request that we correct or amend your PHI
• Request that we restrict the use and disclosure of your PHI
• Request an accounting of how we have used and disclosed your PHI
• File a complaint with the Secretary of the U.S. Department of Health and Human Services if you believe that your HIPAA rights have been violated

How can you contact us?

If you have any questions about this notice or your privacy rights, please contact us at info@acuvedawellness.com.

In addition to the above information, we also want to inform you that we will not use or disclose your PHI for marketing purposes without your written consent.

We are committed to protecting your privacy and will use your PHI only in accordance with this notice and the law.

Photo and Video Consent: 

This authorization grants permission to use your image (still or moving) and/or your spoken words for educational and/or marketing purposes. By signing this document, you agree: To allow the recording of your image and voice (e.g., photographs, audio, or video). 2. To distribute your image or recording in any medium, be it print or electronic form, which may include the Internet. 3. To grant permission to other entities to reproduce the images or recording for educational purposes. 4. That there is no reimbursement for the right to take, or to use your photograph or video, or recording.