Kern Acupuncture

KERN ACUPUNCTURE CORP

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5300 LENNOX AVE., STE 102, BAKERSFIELD, CA 93309 / TEL:661-348-4988 FAX:661-374-4103 INFO@KERNACUPUNCTURE.COM

CANCELLATION POLICY

Due to excessive “cancellations and “no-shows”, I am left with no choice but to reinstate my 24 hours cancellation policy. We have reserved the time and room to accommodate your schedule. If you are unable to keep your appointment, it is your responsibility to provide at least 24 hours notice.

IF LESS THAN 24 HOURS IS GIVEN A FEE OF $25.00 FOR CANCELLATION FEE WILL BE YOUR FINANCIAL LIABILITY.

PLEASE KEEP IN MIND THAT YOUR INSURANCE COMPANY DOES NOT COVER THIS FEE.

I understand an emergency may arise from time to time, preventing you from keeping your appointment. Re-scheduling your appointment in a timely manner will avoid such fee. I have read and understood the policy. I am aware that I will be personally responsible for any cancellation fees. I feel this is a fair policy for everyone in need of acupuncture / consultation service.

I hereby authorize KERN ACUPUNCTURE CORP to charge CANCELLATION FEE based on the policy to

KERN ACUPUNCTURE CORP

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5300 LENNOX AVE., STE 102, BAKERSFIELD, CA 93309

INFORMED CONSENT AND DISCLOSURE

I hereby request and consent to acupuncture treatment and/or herbal supplement recommendations for me (or my legal charge) provided by the KERN ACUPUNCTURE CORP. I understand that the KERN ACUPUNCTURE CORP will explain all known risks and complications, and I wish to rely on the KERN ACUPUNCTURE CORP to exercise judgment during the course of the procedure, which the KERN ACUPUNCTURE CORP determines is in my best interests. I may request another person of my choice to be present in the treatment room during treatment. The KERN ACUPUNCTURE CORP has discussed with me the procedures listed below that may be used in my treatment. I have read the information below and understand the possible risk involved. I agree to the KERN ACUPUNCTURE CORP’s use of this treatment (if indicated).

• Acupuncture is a safe and effective method of treatment. However, it can occasionally cause slight bleeding that usually resolves with pressing dry cotton on the spot where the skin is bleeding. It is also normal for the patient to have a temporary warm, tight, sore or tingling sensation at the acupuncture site.
• Acupressure/Massage involves rubbing, kneading, pressing, and stroking, etc., which may result in muscle soreness at the massage site that can last several days. This technique may require disrobing. I understand all attempts will be made to assure my privacy.
• Indirect Moxibustion requires burning an herbal material near the skin or on an acupuncture needle. Every precaution is taken to prevent skin contact, but the possibility of skin contact and mild burns exists.
• Cupping involves a localized suction produced by heating a small glass cup. There is a possibility of local bruising from the suction and slight burning or blistering due to the heat involved in the technique.
• Tapping, Plum Blossom, Bleeding, Pricking all involve multiple needle pricks at a localized site. Slight bleeding and/or bruising at the treatment site is a likely occurrence. Only single-use needles are used in these procedures.
• Electrical Stimulation/TENS uses microcurrent electricity to stimulate acupuncture points. A mild tingling sensation of electricity will be felt.
• Treatment Using Control Points Ren 1/Du 1. In very rare cases, an acupuncturist may recommend treatment using acupuncture points near the genital organs. If this is necessary, acupuncturist will notify me and will provide alternative treatments if I am uncomfortable with treatment using these points. I understand all attempts will be made to assure my privacy.

I have read, or have had read to me, the above consent, and have had the opportunity to ask questions and discuss this with the KERN ACUPUNCTURE CORP. I consent to the treatment that involves the above procedures for my present condition(s) and any future conditions. I have the right to refuse or discontinue any treatment at any time and understand that this refusal may affect the expected results.

Authorization for Release of Medical Information: I further understand that the KERN ACUPUNCTURE CORP or the KERN ACUPUNCTURE CORP services manager may need to contact my medical physician when the KERN ACUPUNCTURE CORP or the KERN ACUPUNCTURE CORP services manager have identified that my condition needs to be co-managed with my medical doctors. The conditions that may require co-management include but are not limited to; pregnancy related nausea, pain associated with Multiple Sclerosis, neuromusculoskeletal effects of stroke, pain/nausea related to cancer/tumor, chemotherapy related nausea, pain/nausea related to AIDS/ARC, pain or nausea related to surgery. This coordination of care intends to manage my health condition in my best interest and assure the optimal outcome of my acupuncture treatments. Therefore, I give my authorization to the KERN ACUPUNCTURE CORP to contact my medical physician if/when necessary.

Treatment of Pediatric Patients <18 Years. I understand that treatment of young children has some risk and should be coordinated with the child’s physician. If I am signing for my child under the age of eighteen (18), I give my authorization to the KERN ACUPUNCTURE CORP to contact my child’s medical doctor if/when necessary.