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Consent form

Out-of-pocket payment for complementary services and holistic health counseling

This form is for patients who both a) have acupuncture coverage with one of the following insurance providers: Aetna, Cigna or CareFirst / BlueCross BlueShield and b) come in for any complementary services or holistic health counseling. The intention of the form is to clarify out-of-pocket costs for appointments that combine acupuncture and complementary services / holistic health counseling.

I agree to pay for the following services (hereafter “complementary services”) out of pocket:

Cupping
TuiNa

Cranial-Sacral
Gua Sha

Medical QiGong
Holistic Health Counseling

Appointment TypeYour out-of-pocket cost
New Patient Acupuncture + Complementary ServiceCopay/Co-insurance + $25 fee
Follow-up Acupuncture + Complementary ServiceCopay/Co-insurance + $90 fee
Holistic health counseling (60 mins) + AcupunctureCopay/Co-insurance + $150 fee
Holistic health counseling (30 mins) + AcupunctureCopay/Co-insurance + $75 fee

Free Consult—Talk with an acupuncturist, no strings attached!

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