Consent to Participate I acknowledge and agree that I am voluntarily participating in a health fair screening, consultation and treatment. My involvement is as a participant and not as a patient. I further acknowledge and understand that the screening is limited in nature and is not a substitute for seeking medical treatment or follow up with a health care provider.
Types of ScreeningI acknowledge and understand that the health fair is offering the following screenings: Personal health consultation, auricular examination, auricular press seeds, auricular acupuncture, pulse diagnosis, and tongue diagnosis.
Consent for Auricular Acupuncture and Press Seed RisksI acknowledge and understand that I may experience slight pain, bleeding or a bruise at the site of acupuncture or press seeds.
ConfidentialityI understand that Retreat Acupuncture will maintain the confidentiality of the screening results and follow HIPAA . By signing this form, I acknowledge that I’ve been given the opportunity to review this notice.
HEALTH FAIR PARTICIPANT ACKNOWLEDGMENT:My signature below indicates that I have read, or have had read to me, and understand the contents. I believe that I have the knowledge upon which to base consent to participate in the health fair. All questions have been answered to my satisfaction. I hereby give consent to all screenings, consultations and treatments.