By signing below, I hereby request and consent to the performance of acupuncture, massage therapy, and/or nutrition/health counseling treatments, injections, and other procedures within the scope of the practice of these respective forms of care on me (or on the patient named below, for whom I am legally responsible) by a licensed practitioner in the practice listed above. I understand that acupuncturists and massage therapists are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended. I understand that services offered in the practice listed above are not a substitute for medical care. I understand that the practitioners who administer services within the practice listed above are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat physical or mental illness(es).

I understand that acupuncture is performed by the insertion of single use, sterile needles through the skin, at certain points on or near the surface of the body, with or without electrical stimulation and/or Nerve Reboot, in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, regulate and balance Qi (energy), improve organ function and overall health, and to normalize the body’s physiological functions. I understand that methods of treatment related to acupuncture may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, injections, and nutritional counseling. I understand that while needle insertion is a large part of the acupuncture treatment, it does not encompass the entire treatment during the appointment. I understand that the appointment time is in sixty-minute increments, however, my time in the treatment room may not reach a full sixty minutes. Needle insertion can be in the range of 25-45 minutes and my sixty-minute appointment time also includes the provider’s documentation of the treatment, which may occur after my appointment time. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

Acupuncture typically involves safe methods of treatment; however, certain adverse side effects may result. These rare and unusual side effects could include but are not limited to, minor bruising or bleeding, soreness, numbness or tingling near the needling sites that may last a few days, dizziness, fainting, infection, spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue.

I will notify a clinical staff member who is caring for me if I am or become pregnant. I understand that if am pregnant, I am not eligible to receive QiGong Massage Therapy (QMT) services by this office and it is not recommended that I seek these services elsewhere. I understand that if I have had a recent surgical procedure, I must receive prior approval by a physician in writing and disclose this information to the treating practitioner before receiving massage treatment to protect my health and safety. I understand that there are risks involved with any medical procedure or service. I agree not to hold HHA liable for anything related or resulting from care received by any of our licensed and trained providers, and agree to engage in the services provided at Holistic Health Associates at my own risk. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment. I understand that results are not guaranteed and that I am free to stop the treatment at any time. I understand that while this document describes the major risks of treatment, albeit rare, there are other side effects that may occur. I understand the clinical and administrative staff may review and discuss my patient records and lab reports within the practice, but all my records will be kept confidential and will not be released without my written consent. I affirm that I have notified my therapist of all known medical conditions in writing (medication and supplements, surgeries, and injuries) to identify contraindications for massage and acupuncture. I do agree to inform the practitioner of any changes in my health and medical condition(s) and I understand that there shall be no liability on that of the practice if I forget to do so or omit and information on my Intake Form. I understand that by signing this release, I hereby waive and release this practice listed above and its employees from all liability, past, present, and future relating to the services rendered.

I understand that all services rendered at Holistic Health Associates are entirely therapeutic and non-sexual in nature. I understand that Acupuncture, Massage and Reiki therapies are provided for stress reduction, relaxation, relief from muscular tension, and/or improvement of circulation and energy flow. I understand if unethical and inappropriate conversation, behaviors and/or actions are observed before/after/during any service or session rendered in this practice, the service will end immediately, my account will be flagged, and I will no longer be permitted to schedule future services.

I understand that I must be able to independently journey to my designated treatment room, undress to my comfort level, and transfer on and off the treatment table safely without assistance from practitioner or other staff unless discussed prior to my scheduled treatment. I understand that if more assistance is needed, I am required to bring a caregiver to assist me in these tasks.

I understand that any child/minor (under the age of 18) must obtain and provide prior approval in writing. I understand that any child/minor (under the age of 18) must also have a parent or legal guardian present during the service rendered for its entirety.

I understand that if my practitioner must cancel my scheduled service for any reason, I will be offered the option to reschedule.

Holistic Health Associates engages in electronic communication services. This includes video and audio telehealth appointments using a compliant platform, text message and email communication with staff through our private system, and automated appointment reminders. Our practice will use all reasonable means to protect the security and confidentiality of information sent and received. However, because of the risks outlined below inherent to all electronic communications, the security and confidentiality of electronic communications cannot be guaranteed. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments.

• Use of electronic communications to discuss sensitive information can increase the risk of inadvertent disclosure of such information to 3rd parties.
• Despite reasonable efforts to protect the privacy and security of electronic communications, it may not be possible to completely secure electronic information.
• Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the participants.

By signing this document, I understand and accept the risks associated with the use of electronic communications as outlined above and consent to the use of these means to communicate with this practice and its employees.

I understand that even if I have received one or more doses of the Pfizer, Moderna, or Johnson & Johnson COVID-19 vaccines, there is still potential risk to contract or transmit bacteria/viruses to others while in close contact for an extended period of time, directly or indirectly. I understand that because therapies and services rendered by Holistic Health Associates involve maintained touch and/or close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. I understand that I should speak with our office regarding any illness symptoms I am experiencing so that HHA may guide me to the best course of action that aligns with HHA’s current COVID policies. I understand that if I am experiencing symptoms, my appointment may need to be rescheduled. I understand that this practice and all employees take safety measures seriously for both staff and patients alike, however, there is no guarantee to remove all risk of exposure to COVID-19 or any other communicable disease, bacteria or virus. I understand that education regarding COVID-19 is still formulating and therefore, our practice’s policies around COVID-19 are subject to change. I agree to adhere to all COVID-19 policies made known to me, set by this practice.

By voluntarily signing below, I show that I have carefully read, or have had read to me, all the above information and have been told about the risks and benefits of acupuncture, massage therapy, and other procedures and therapies. I have had an opportunity to ask questions and am fully aware of what I am signing. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment or until a new form is signed and retained on file by this practice.