CAIN ACUPUNCTURE AND HERBAL MEDICINE
Clint Cain, M.S.O.M., Dipl. O.M., L.Ac.
1723 Canyon Boulevard
Boulder, CO 80302
618-694-5189
ccain85@yahoo.com
Colorado Mandatory Disclosure Statement
Clint received his Master’s of Science in Oriental Medicine from Southwest Acupuncture College
(SWAC) in Boulder, CO, April 2014. He began his acupuncture and Chinese herbal medicine education
at Pacific College of Oriental Medicine (PCOM) in Chicago, IL. At PCOM he received a strong
foundation in the fundamentals of Chinese medical theory, acupuncture therapy, and herbal medicine.
Clint transferred to SWAC in order to study Kototama Inochi Medicine, a style of Japanese acupuncture
focusing on pulse diagnosis, bodywork, and moxibustion therapy, with Ted Hall, L.Ac. Clint continues
to refine his understanding of acupuncture alongside his teacher in a traditional side-by-side and handson fashion. Additionally, he is currently undergoing advanced studies in Canonical Chinese Medicine, a
very powerful and effective system of classical Chinese herbalism, under the direction of Arnaud
Versluys, Ph.D., L.Ac. Clint is nationally certified as a Diplomate of Oriental Medicine (2014), meeting
the requirements of at least 1,490 hours of clinical and classroom training in acupuncture and
biomedicine, as well as 2,050 hours of clinical and classroom training in Chinese herbal medicine. He is a
Licensed Acupuncturist in the state of Colorado. None of his licenses or certifications have ever been
suspended or revoked, nor has he been subject to any disciplinary action in any jurisdiction.
Fee Schedule:
Initial Consultation with Acupuncture Treatment, 1-1.5 hours: $90
Acupuncture Treatment, 30-60 minutes: $75 + price of herbs, if applicable
Herbal Consultation Only, 20-40 minutes: $45 + price of herbs
Payment is due at the time of treatment. Detailed receipts are available for all transactions, which
includes all information necessary for your insurance company. If the health insurance coverage you
have purchased covers acupuncture treatment, it is your right to receive compensation for that
treatment as per the conditions of your policy. You are entirely responsible for all communication with,
and reimbursement from, your insurance company. Cain Acupuncture and Herbal Medicine will not bill
your insurance company for you, and cannot guarantee any coverage for treatment. Please be advised
that there is a processing fee of 2.75% for credit card transactions. Additionally, you may be
charged $40 for any appointments broken without 24 hours prior notice, and there is a $20 fee
for returned checks.
Please be advised that only the person for whom the appointment is scheduled shall be the one to make
said appointment if more than one appointment is ever missed without advanced notice of cancelation,
with the exception of persons age 14-18, or with prior written consent.
Patient’s Rights:
- The patient is entitled to receive information about the methods of therapy, the techniques used,
and the duration of therapy, if known.
- The patient is entitled to seek a second opinion from another healthcare professional, and may
elect to terminate therapy at any time.
Side 1 of 2
Clint Cain, M.S.O.M., Dipl. O.M., L.Ac. • 1723 Canyon Blvd., Boulder, CO 80302 • (618) 694-5189 • ccain85@yahoo.com
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In a professional relationship, sexual intimacy is never appropriate and should be immediately
reported to the Director of the Division of Registrations in the Department of Regulatory
Agencies.
Acupuncture and moxibustion are among the most significant and routinely performed treatment
procedures for healthcare maintenance and restoration amid the numerous methods of Oriental
medicine. They involve the insertion of sterile needles into the superficial layers of the body, along with
the application of a minimal amount heat to said needles. As is the case with all forms of medicine, there
are potential risks involved with treatment including, but not limited to, local bruising, minor bleeding,
pain or discomfort, or localized reddening of the skin. All precautions are taken to minimize risks as
much as possible. You will receive unique and personalized care specifically adapted to your condition.
However, no particular results can be guaranteed, especially without a certain degree of patient
compliance and personal responsibilities.
This clinic complies with the rules and regulations set forth by the Colorado Department of Health,
including proper cleaning and sterilization of needles and the sanitation of the acupuncture office(s).
Only single-use, disposable, factory-sterilized and sealed needles are used in this clinic.
Chinese herbal medicine encompasses the use of various substances of plant, mineral, or animal origin.
These products are considered to be extremely safe and effective, but some side effects may occur. These
may include, but are not limited to, changes in appetite or digestion, loose stools, rashes, tingling of the
tongue, or headache.
Your file, along with any and all information given and discussed in the context of treatment, is
considered confidential, and shall not be released without your written consent, except as required by
law.
The Colorado Department of Regulatory Agencies regulates the practice of acupuncture. Any questions,
comments, or complaints may be directed to the Director of the Division of Registration in the
Department of Regulatory Agencies at the Acupuncture Registration Office, 1560 Broadway, Suite
1350, Denver, CO 80202. Telephone: 303-894-7800.
E-mail: DORA_AcupunctureBoard@state.co.us
I have read and understand the points covered in this document. I agree to pay my account at the time of treatment,
regardless of my insurance status. I understand and agree to the scheduling policy, as well as my rights as a patient.
I hereby consent to and authorize treatment by the practitioner(s) at Cain Acupuncture and Herbal
Medicine.
Name____________________________________________Date_________________
Side 2 of 2
Clint Cain, M.S.O.M., Dipl. O.M., L.Ac. • 1723 Canyon Blvd., Boulder, CO 80302 • (618) 694-5189 • ccain85@yahoo.com