Sandy Evans L.Ac., M.Ac.OM
2455 NW Marshall St, Suite 10
Portland, OR 97210 503-333-9870
Patient Consent to Treat
Patients Name (Please Print)__________________________________________________________________
I hereby consent to the following:
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Treatment: Any and all health care and treatment, which may include acupuncture, electrical acupuncture,
tui na massage, cupping therapy, moxibustion, herbal formulas, nutritional counseling and/or therapeutic
exercises. I understand that needling and cupping may cause bruising in some cases. I understand that on
very rare occasions dizziness or fainting may occur while receiving treatment. During moxibustion there is
a possibility of hot ash falling onto the skin and causing discomfort or burning sensation. The
acupuncturist will take every precaution to prevent ash falling onto the skin. In extremely rare instances
there is the possibility of nerve damage or pneumothorax occurring during acupuncture. The acupuncturist
will take every precaution necessary to avoid nerve damage and pneumothorax. The clinic uses sterile
disposable needles and maintains a clean and safe environment. I understand that some herbs are
inappropriate for pregnancy and I will notify the Acupuncture Physician if I am or become pregnant. Some
rare but possible side effects of herbs are bloating, gas, nausea, dull headache or loose stools. I understand
that the Acupuncturist is a Licensed Board Certified Herbalist and has appropriate training to prescribe
herbal medicines. I understand that Acupuncturist only prescribes herbs that she considers to be of benefit
for the patients health and well-being. I understand that rare and unforeseen allergic reactions or other such
reactions may occur in some patients. I will notify the Acupuncturist if I experience any discomfort.
Financial Information: All professional fees are due in full at the time services are rendered, unless prior
arrangements have been made with the patients health insurance company. I hereby acknowledge and
accept full responsibility for all costs incurred. I understand that I am responsible for any remaining
balance after the insurance company reimbursement as well as co-payments, deductibles and any denied
claims. Payments are made directly to Sandy Evans L.Ac.
Authorization to Use and Disclose Health Information: I authorize the release of my medical information
to my insurance company for the purpose of assessing claims. This information includes records of
examination, diagnosis, treatment and billing information during the duration of care. I authorize my
insurance company to make payment of medical benefits directly to Sandy Evans LAc. This release of
information expires one year after termination of care.
CANCELLATION POLICY: Please be considerate and cancel appointments at least 24 hours in advance.
I affirm that I have read and understand the above and consent to treatment.
Signature:_____________________________________________________ Date:___________________________
Birthdate:_____________________________________________________________________________________