Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-

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Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.- INFORMED CONSENT Acupuncture involves the insertion of special needles into particular points on the body. The purpose of this treatment is to prevent or reduce pain and to help your body function better. There are some risks to treatment, including the possibility of bruising of the skin and/or slight bleeding, weakness, fainting, and/ or the aggravation of symptoms existing prior to acupuncture treatment. There is little to no risk of infection when all needles are sterile. PhxCA uses only one-time use, sterile disposable needles. We do not reuse needles. PhxCA does not provide primary care, nor Western (allopathic) care. Please see your medical doctor for those services and for routine check-ups. If you are pregnant, have a bleeding disorder, pacemaker, high blood pressure, local infection, or have been prescribed anticoagulant medications like Coumadin, we can still treat you but should be made aware of your condition. By signing below you state that you have informed your acupuncturist of such conditions. I understand the risks and I voluntarily consent to the above procedures. RELEASE OF LIABILITY FOR LOST OR STOLEN GOODS PhxCA is not responsible for lost or stolen goods. I release Phoenix Community Acupuncture from liability for lost or stolen goods. PRIVACY POLICY PhxCA takes the right to your privacy seriously. We do not disclose any personal, health, financial, or any other information about you, or services we provide to you to any third parties without your request or permission. This includes online services we provide, including access to your appointment information, user ID, or password. I understand Phoenix Community Acupuncture Privacy Policy. CANCELLATION/ELECTRONIC RECEIPT POLICY Phoenix Community Acupuncture makes every attempt to make acupuncture available to as many people as possible, at the most affordable rates. Because our intention is to offer high-quality healthcare at affordable prices, we ask for at least 4-hour advance notice if it is necessary to cancel an appointment. All appointments that are cancelled with less than 4-hour advance notice, and appointments missed without notice, will be charged $10 for that appointment. If appointments have been purchased in a package, the missed or cancelled appointment will be deducted from the number of remaining appointments in that package. I am aware that if I provide my email or phone number to Square credit card reader, then they will email or text me receipts from PhxCA purchases I agree to Phoenix Community Acupuncture s Financial Policy

COMMUNITY SPACE ACKNOWLEDGEMENT I understand that - Community acupuncture is a high volume model, my acupuncturist may not look at my chart before seeing me. I will tell the acupuncturist my symptoms each time. - If I need to be woken up at a certain time, I will let the acupuncturist know. - I might be too relaxed to drive immediately after treatment. - If other people s snoring bothers me, PhxCA has ear plugs available for 25. Personal headphones may also be used so long as they are not distracting to other patients. - In a community space whispering and turning off my cell phone are necessary. - I have the option to write down in a note any issues that I want to inform my acupuncturist of but do not want to speak about in a community setting. - For safety reasons, if I need a blanket, I will tell my acupuncturist and they can get it for me. - If I have a cough for any reason, I will be asked to wear a mask which PhxCA can provide. - If I am experiencing flu-like symptoms (fever, nausea/vomiting, diarrhea, etc.), I will stay home and not come to PhxCA for acupuncture until I am well. - I need to eat and drink enough water before treatment. - For best results, loose clothing, that can be rolled to elbows and knees, is advised. - If I am taking recommended herbal supplements and I experience adverse reactions, I will stop taking the herbs and notify the clinic immediately. - Acupuncture needle are very small; and PhxCA needs to treat a high volume of patients in order to keep its prices low; and so I may need to help my acupuncturist locate all of the needles at the end of my treatment and before I leave the clinic. - I am willing to participate in my own treatment process. I agree to an intake, a treatment, and follow ups in a community space. CLINIC RULES I will not walk in the clinic with bare feet, I will not leave my chair while needles are inserted, I will alert the staff if I see a needle on the floor, but I will not touch it; I will not remove my own needles. I agree to follow the clinic rules. By signing below, I agree to the policies, consents and release of liability as set forth on the entirety of this document. Signature Date / /

2530 N. 7 th St. Phoenix, AZ 85006 623-242-0541 PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Gender Preferred Pronoun How did you hear about us? CONTACT INFORMATION Phone Email Would you like to receive our monthly newsletter? YES / NO Another person we may contact if needed: Name Relationship Phone HEALTH HISTORY What would you like to receive treatment for? 1-2 - 3 - Rate the severity of above issues 0-10 : How is your sleep? How is your digestion? List medications or food supplements you are taking. List serious illnesses, accidents or surgeries from the last 5 years Do you currently have flu-like symptoms (fever, nausea/ vomiting, diarrhea, etc)? Date of last menses Could you be pregnant TRAVEL HISTORY Have you traveled out of the region within the last 30 days? If yes, where?

HEALTH HISTORY CONTINUED Check symptoms you have or have had in the last year: Depression AIDS/HIV Hepatitis B or C Dizziness Anxiety Excessive anger Fatigue Headaches Anemia Arthritis Cancer Diabetes Neuropathy Epilepsy Tremors Asthma or difficulty breathing Blurred/failing vision Ear pain Eye pain Hearing loss Ringing in ears- high or low pitch (circle one) Cough Sore throat Bruise easily Itching/rash Night sweats Tend to feel hot easily Tend to feel cold easily Blood in urine Kidney infections/stones Low libido Chest pain High blood pressure Low blood pressure Heart palpitations Diarrhea Constipation Indigestion/heartburn Nausea Stomach pain Poor appetite Vomiting Prostate trouble Excessive menstrual flow Menstrual cots PMS/PMDD Amenorrhea (period has stopped) Menopause History of miscarriage PCOS Undergoing fertility treatments SIGNATURE The information on this form is correct to the best of my knowledge. Signature Date

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