Initial Visit Form & Consent

Please submit the form below prior to your first visit. Thank you for your cooperation and we look forward to working with you. Any questions can be emailed to info@refugemarin.com

Name

Email and Phone Number

Date of Birth

1. What is your Prima Materia or primary symptom?

2. How does this affect your life?

3. What are your goals for healing? (If we had a magic wand...)

4. How is your Body? Is there an obvious structural, environmental, pathogenic, or physical trauma?

5. How is your Mental & Emotional Health? Are there any obvious blocks to healing such as anxiety, focus, overworking, overpowering emotions or emotional trauma?

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of my practitioner at Refuge Marin. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, Reiki, Gua Sha, herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to: bruising; numbness or tingling near the needling sites that may last a few days; and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am nursing. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure. I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter). No Guarantees About Contact with COVID-19. I understand that while the acupuncturist is following all the health and safety guidelines and taking all reasonable precautions to clean and disinfect the clinic and all the surfaces within, there are no guarantees that I may not come in contact with COVID-19. I understand and I also agree to defend, indemnify and hold harmless the acupuncturist from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against her as a result of my having this treatment performed, or from my visiting her workplace. By voluntarily checking below, I confirm that I have read, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I agree to the terms & conditions.

Type Name for Signature

Thanks for submitting!

REFUGE

MARIN

Initial Visit Form & Consent