Acupuncture has been used as a medical therapy for over two thousand years in the orient. Here in the west we have only
begun to research its efficacy and mode of action. Acupuncture, nevertheless, has gained recognition as a standard method
of treatment by the American community at large. We have observed good results from its use and know of very few problems
I authorize Melanie J. Myers, a National Board Certified, and State Licensed Acupuncturist, to administer Acupuncture,
which primarily involves the insertion of needles at one or more points on the body,or non-needle methods of acupuncture and
Oriental Medicine healthcare modalities such as cupping, qi gong, heat/cold applications,Tui Na(form of asian body work simular
to massage), auricular therapy(ear acupuncture), electro-stimulation acupuncture via micro and milli-amperage, dietary, nutrition
and herbal counceling, facial rejuvenation.
I understand that all questions posed by me regarding the procedures to be used will be answered prior to receiving my
initial treatment and in no manner have I been guaranteed a beneficial result from treatment even though acupuncture is shown
to be very affective for many disorders.
I understand that in consideration of the time reserved for me that I will be charged for a full office visit for any
cancellation not made 24 hours in advance.
I understand that there is a $30.00 fee for each returned check. I further understand that in the event of third party
reimbursements, or otherwise, I shall be personally responsible for all attorney and court costs to secure any unpaid balance
to this office.
I have read and understand the above statements and I consent to the use of Acupuncture and/or allied techniques.
Parent signature(if minor)_______________________________________