Colorado Mandatory Disclosure & Informed Consent
True North Acupuncture & Holistic Medicine
This disclosure statement is in compliance with the State of Colorado, Department of Regulatory Agencies, Colorado Title 12 Article 29.5. All rules and regulations set forth by the Department of Health are strictly adhered to, including proper cleaning, sterilization, and sanitation of equipment and office. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have any comments, questions, or complaints, contact the Acupuncturists Registrations Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-2440. The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registration in the Department of Regulatory Agencies.
Practitioner Education, Certification, and Experience:
Katie Hale, Dipl. OM, L.Ac- earned her Master of Science in Oriental Medicine from Colorado School of Traditional Chinese Medicine in 2012. NCCAOM Diplomate in Oriental Medicine (acupuncture and Chinese herbology) in 2012. Licensed in Colorado by DORA in 2012. Colorado Licensed Acupuncturist, license #1836. Licenses, registrations or certifications have never been revoked. Education included a 2,850 hours program, with over 1,000 hours of clinical experience. Also has clean needle technique certification, as well as training in adjunctive therapies, such as moxibustion, tuina, acupressure, cupping, auriculotherapy, Chinese herbology and dietary and lifestyle recommendations.
Emily Sealy, L.Ac, Dipl. OM, Usui & Karuna Reiki Master. Master of Science in Traditional Chinese Medicine from Colorado School of Traditional Chinese Medicine. Nationally board certified as a Diplomate in Oriental Medicine by the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM #846582). Licensed Acupuncturist of Colorado (#ACU.0002654). No license, certificate or registration has ever been revoked or suspended.
Informed Consent
I hereby request and consent to the performance of acupuncture procedures by my practitioner, Katie Hale or Emily Sealy. I have been informed that acupuncture is a safe method of treatment but that I may have side effects including discomfort, pain, dizziness, bruising, or numbness at the site of the procedure. Unusual and rare risks of acupuncture include nerve damage, organ puncture including lung puncture, infection, and spontaneous miscarriage. Other side effects and risks may occur. If I am pregnant, I will immediately inform the practitioner. I have discussed the nature and purpose of my treatment with the practitioner named above. I understand that there are no guarantees regarding cure or improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest, I may be referred to another practitioner or other health care provider who may be more qualified to treat me outside of these facilities. I do not expect the practitioner to anticipate and explain all possible risks and complications, and I permit the practitioner to determine and/or alter the course of treatment which the practitioner judges to be in my best interests based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time. I have read or have had read to me the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment.
We are out-of-network providers but most insurances now cover out-of-network acupuncture, whoop. We are happy to provide a master bill to submit as reimbursement claim through your insurance provider. So call your insurance company to check your benefits.
Clinic Fee Schedule (due at the time of service, non refundable)
We require a 24-hour cancellation notice prior to all scheduled True North Acupuncutre and Holistic Medicine appointments; otherwise, you will be charged the full scheduled treatment rate. All treatments are nonrefundable.
5 Pack: Purchase five follow-up treatments at $440. All pre-paid package/services are non-refundable and will expire 6 months from date of purchase.
I understand that I may request and review the privacy practice for True North and understand the situations in which this practice may need to utilize or release my medical records. I also understand that I agreed to the use of those when I initiated care at this office on my first visit, whenever that may have occurred.
I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this privacy practices statement.