N. Elizabeth Cox, LAc, Sarita Devi Enterprises, Inc
1715 23rd Ave , Meridian, MS 39305, 205.310.7197
InformedConsent:
Oriental Medicine therapeutic procedures are considered safe and effective methods of care. However, on
occasions, complications may arise; any procedure intended to help may have complications. While the
chances of experiencing complications are small, it is our practice to inform our patients about them. These
complications may include, but are not limited to soreness, inflammation, soft tissue injury or bruising,
dizziness, burns, temporary worsening of symptoms. More serious complications are extremely rare.
Additional information on side effects or complications as well as more details about techniques used is
available upon request. Please inform your practitioner if you have any blood clotting disorder or are
currently taking any blood thinning medication. In compliance with the law it is also our policy to inform
you about acupuncture, including the techniques used and course of treatment. If the practitioner does not
explain to your satisfaction, please ask for more information. Acupuncture is an ancient Asian medical
practice. Energy call qi (pronounced chee) circulates via pathways (meridians) to all parts of the body.
When the flow of qi is impeded or disturbed, pain or illness occurs. The insertion of flexible, sterile
filament needles into precise points on the body helps restore the smooth flow of qi, which balances and
harmonizes the body systems. Electromagnetic research has confirmed the existence and location of these
points. When performed by a competently trained, licensed professional, acupuncture is generally safe.
Licensed acupuncturists today use individually packaged, sterile, disposable needles. The needles are
typically not much thicker than a hair, and their insertion is generally not painful. Activation of the points
is typically creates a fleeting sensation in the body. Most people find acupuncture very relaxing, and many
fall asleep during treatment. According to the state law of Mississippi, acupuncture is not a substitute for
conventional medical diagnosis and treatment. The number of acupuncture treatments depends on the
duration, severity and nature of your complaint. You may need a single treatment for an acute condition; a
series of 5-12 treatments may resolve many chronic problems. Some degenerative conditions may require
many treatments over time. Some people choose to utilize acupuncture as part of their preventative
wellness plans when they are symptom free to optimize their health. The frequency of these treatments may
be weekly to monthly or seasonally.
Agreement to Payment Policy
By signing this form, I understand that full payment for all services and products I receive is required at
time of service. I understand that I can request a bill that I can submit to my insurance carrier for
reimbursement purposes, and that I am responsible for any services not covered by my insurance company
or flex spending plan, as well as any co-pay, coinsurance or deductible required by my insurance.
We hold a 24hour cancellation policy for all appointments. Generally, even with 24hrs notice, we cannot
fill the appointment time. Therefore, we charge the full fee with less than a 24 hour notice.
Agreement to Electronic Scheduling and Email Correspondence
N Elizabeth Cox, LAc, or a person on her behalf may use email to correspond with or schedule patients as a
convenience. By signing this form you are consenting to Elizabeth Cox to correspond with you via email
and scheduling appointments electronically in spite of these potential risks. However, these electronic
correspondences are not encrypted and could theoretically be read by a malicious outside party with the
technical sills to intercept such correspondences. We respect patient confidentiality and we are required by
the State of Alabama and Federal Law to maintain the privacy of your protected health information(PHI).
Your health record contains PHI about you and we are required to follow the privacy practices described in
this Notice.
I have read and understand the above statements regarding acupuncture treatments and techniques, effects,
payment and electronic correspondence. I also understand that there is no guarantee for a specific cure or
result.
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Signature of Patient
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