COVID-19 CONSENT TO TREAT FORM
FILL IN FORMS ONLINE, PRINT, OR PICK UP forms before your appointment to complete.
ACUPUNCTURE: Traditional Chinese Medicine intake forms are lengthy because they examine the entire body in detail.
MASSAGE: Fill out forms prior to appointment or arrive 15 mins before your appointment time to do so.
ACUPUNCTURE: Drink extra water for 24 - 48 hours if Cupping or Gua Sha is applied.
MASSAGE: To help prevent prolonged soreness, dehydration & support the lymph system:
ACUPUNCTURE & MASSAGE: Use the facilities prior to your session. Before you arrive or in office. It's easier to relax without a full bladder!
ACUPUNCTURE: All points are swabbed with alcohol before the insertion of needles. Taking the extra step of being clean will help prevent the risk of infection.
MASSAGE: Taking a shower before your appointment is important if you are visibly dirty or smelly.
ACUPUNCTURE: It's best not to exercise after treatment. Rest & relax.
MASSAGE: Exercise after massage may:
NO EXERCISE AFTER MASSAGE.
Drug & Alcohol use can decrease the awareness of pain.
ACUPUNCTURE: Acupuncture has been known to increase the effects of alcohol & should not be consumed the same day as your appointment.
MASSAGE: Being dehydrated before or becoming dehydrated after can cause or increase possible side effects.
ACUPUNCTURE: It can help stop the progression of illness, cold or flu symptoms depending on the stage & intensity.
MASSAGE: Dehydration & lymph movement stress the immune system. Having bodywork while you are ill will increase the severity & duration of the illness
ACUPUNCTURE & MASSAGE: Having a full stomach can cause you as much discomfort as an empty one.
BLOOD SUGAR LEVELS can be influenced by both Massage & Acupuncture. Please bring any testing or insulin supplies that may be needed.
ACUPUNCTURE: Wear clothes that can be rolled up to expose the feet, legs to above the knee, hands & arms to above the elbow. If points aren't accessible, a gown will be provided.
NO BODYWORK ON AREAS THAT ARE SUNBURNED, WINDBURNED, OR INFECTIOUS.
Eczema, psoriasis & other chronic or non-infectious skin conditions can usually be worked around depending on the affected area's size, severity & location.
Submit forms online at your own convenience! Forms have been provided in a secure & private patient portal, that you can fill in & submit online prior to your appointment.
You can also send the practitioner secure messages & schedule appointments. If you need help with the patient portal please visit the SCHEDULE page for step by step directions.
If you'd prefer to fill your forms out by hand, links are provided below.
Download, print, & bring your completed forms to the office before or at the time of your appointment. You can also pick up forms in the office.
Our Privacy Practices are detailed as required by HIPPA. Protects patient's Personal Health Information.
Patient's signature for Privacy Practices as described in the document above.
By signing, you are agreeing to this American Acupuncture Council Arbitration Agreement, you are agreeing to settle any malpractice complaints in legal arbitration rather than in court. Costs for such proceedings will be paid for by both parties no matter the outcome. Intended to prevent frivolous lawsuits.
By signing, you are consenting to treatment with the full understanding & disclosure of the risks associated with receiving care during the COVID-19 pandemic.
By signing, you are consenting to all forms of treatments associated with the practice of Traditional Chinese Medicine the practitioner is permitted to perform.
Signature required by the Iowa Board of Medicine, licensing board for acupuncturists. This details service rates. The practitioner's education, degrees, certificates, & scope of practice as defined by the Iowa Board of Medicine are also included.
Required details for all new acupuncture patients EXCEPT those seeking FERTILITY treatment.
Required details for all new acupuncture patients, including Men's Fertility patients.
Printable combination of both Questionnaire & Checklist.
Required details for all new female acupuncture patients, including FERTILITY patients.
Required only for women seeking acupuncture for fertility issues.
Required only for men seeking acupuncture for fertility issues.
Consent signed that details the benefits, possible side effects, & contraindications for Massage Therapy.
Patient details their health information concerning the condition(s) they are seeking treatment for.
Only patient's seeking services after being in a recent car accident for detailing the circumstances. Massage Therapy Health Information also required.
Signed for Cupping Therapy.
Signed for Auricular Therapy.
Signed for Herbal Therapy.
Signed for Moxibustion use.