I,                       write name below                                                      consent to Chinese medical treatment by Bethany M. Leddy. I understand that Chinese Medical treatments involve the use of acupuncture needles, moxa heat therapy, and/or herbal medicines.   I understand that I have the right to refuse any treatment at any time and to discontinue treatment whenever I wish.

All information discussed during your treatment is privileged and confidential. I do consent to the release of my medical information to my insurance company or to other Doctors I am seeing regarding my condition. I also consent to the anonymous use of my data for research purposes.

I also understand that it is important to regularly consult my physician regarding my condition and for routine physicals.

Payment is expected at the time of visit in the form of cash, check or credit card. Our office only bills insurance companies with prior authorization where the deductible has been met. I can also provide you with an insurance reimbursement form to assist you in filling out insurance claim forms. The link to verify insurance is contained in your welcome email and also on the website. Because of the reimbursement policies of Blue cross blue shield we do not bill BCBS directly. This office makes no guarantees or claims that insurance will reimburse the patient for treatments.

I agree to give 48 hours notice before cancellation or change of an appointment. If I fail to give 48 hours’ notice before cancellation, I agree to pay the full amount of the missed or canceled appointment.

I also certify that I do not have any known Covid-19 symptoms, do not currently have a positive Covid-19 diagnosis, and have not had close contact with anyone recently diagnosed with Covid-19. Covid-19 symptoms include but are not limited to: fever, chills, severe headache, loss of taste or smell, cough, chest pain, shortness of breath, stomach pain, nausea, vomiting, or diarrhea. I must respond to the Covid-19 prescreening email prior to each visit to certify that I do not have Covid-19 symptoms. During this time of Covid-19 any suspected viral or bacterial illness is considered Covid-19 until a negative PCR Covid-19 test is given. The 48 hour cancellation policy is waived if Covid-19 symptoms are present.

 Please provide name and initials below to indicate signature on file.