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AHh Clinic
4410 W. 98th Street Circle, Bloomington, MN 55437
(952)484-0943, Fax:
Welcome, AHh Clinic is committed to provide the best quality services and the best herbal remedies to
our patients. Please take a moment to read our office policies and sign the informed consent and the
following forms.
Office Policies
We do not discriminate based upon age, gender, race, religious, sexual orientation or health status.
We welcome and accept any insurance network and we do take all insurance policies. If you are
under any health insurance plan that covers acupuncture or herbs, we will submit the claim for you to cover
the cost of treatment; for the remaining balance, if any, will be your total responsibilities. If you do not have
any insurance policy or your insurance policy does not cover acupuncture or herbs, payments for service
and herbs may be made by cash, personal check or paid by credit card.
Privacy Policies
We are committed to protect patient confidentiality and privacy. We will work side by side with your
open-minded physicians. To provide the integrated service and care, we may disclose medical information
to your primary physicians with your written consent. To protect your confidentiality, your identity and your
medical records will NOT be disclosed to any financial institution, creditor, insurance institution, marketing
company, pharmaceutical company, polling organization, or your employer. We reserve the right to change
our privacy policies; however, you will be notified if there is a change.
Cancellation Policies
Your appointment is reserved for you. Your missed appointment is a missed opportunity for another
patient to receive treatment; therefore, it is your responsibility to inform us for your cancellation 24 hours in
advance.
_____ I authorize AHh Clinic to contact my primary care physicians regarding my medical condition,
medication, medical providers or any upcoming medical procedures so that my total health well-being can
be improved.
_____ I agree to inform AHh Clinic any change in my medical condition, medication, medical providers, or
any upcoming medical visit or procedure.
_____ I agree to receive complementary therapies, which may include a combination of, but are not limited
to acupuncture, electrical stimulation, moxibation, Chinese herbal medicine, Tui Na, cupping, Gwa Sha,
blood letting, acutomology, or leech therapy(on demand only). If you have questions, please ask for
explanations.
_____ I understand that the above mentioned therapies are safe methods of treatment; and I understand
that all herbal prescriptions used at AHh Clinic are considered safe in the practice of Chinese medicine.
However, some unforeseen conditions such as allergic reactions or hematoma etc. may occur. If I am
pregnant or if I wear a pacemaker, I will notify AHh Clinic immediately so that I will avoid unnecessary
contraindications.
_____ I agree not to manipulate acupuncture needles myself so that I will avoid any unnecessary physical
discomfort or damage.
_____ I agree not to come for service under the influence of alcohol or drugs; and I understand that if my
behavior does not comply with the policy of AHh Clinic, I may be refused treatment, suspended from
treatment or dismissed as a client.
I have read and agree the above consent and statements.
Name (print) ___________________________ Signature _____________________
Your email: _____________________________________________________________________