• By signing below, I acknowledge that I have read, understand, and agree to the statements and policies listed below.
• I understand that the treatment can be terminated at any time by either myself or the therapist upon verbal request.
• I understand that the Licensed Massage Therapist ( L.M.T. ) does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. It is recommended I work with my PCP for any condition I may have. I have stated all known conditions and medications, and I will keep all providers updated on changes.
• I hereby request and consent to the performance of therapeutic massage and/or acupuncture and Chinese medicine which may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Massage), Chinese herbal medicine, botanical medicine, cosmetic acupuncture, JMT, homeopathy, gua sha, and acupuncture injection therapy, and other complementary and alternative medicine treatments as requested. I will immediately notify clinic staff of any unanticipated or unpleasant effects associated with the consumption of herbs or any other botanical or nutritional supplement.(See next page for additional chiropractic care consent)
• I understand that all fees are due at time of treatment unless prior arrangements have been approved. I understand that I am responsible for all collection costs, interest, and appropriate legal fees for the collection of any unpaid debts to Peaceful Spirit Therapeutic Massage Centers LLC. or their affiliates.
• Peaceful Spirit Therapeutic Massage Centers LLC is pleased to file an insurance claim (in pre-approved cases) for you in the case of personal injury, worker's compensation, or health insurance. Please understand that the benefit contract is an agreement between you and the insurance company (or your employer or at-fault party's insurance company) and that verification of benefits is not a guarantee of payment. You are fully responsible for any and all services rendered to you. All reasonable efforts will be made to collect sums due from the insurance companies that are contractually obligated. If you receive a payment from the insurance company, this payment must be brought into the office and shall be applied to the balance due. I assign directly to Peaceful Spirit Therapeutic Massage Center LLC, or its divisions all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, even if prior authorization was granted.
• I acknowledge receipt of Notice of Privacy Practices available under separate cover. I hereby authorize Peaceful Spirit Therapeutic Massage Centers LLC, or its divisions to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all submissions. A photocopy of the assignment lien and my signature shall be considered effective and valid as the original.
• I understand that COVID-19 is a highly contagious respiratory infection that is potentially life threatening. I am aware that the provider may decide to reschedule if I have been sick, febrile, or have COVID-19 according to his or her discretion. I have had the opportunity to ask questions and seek clarification with the provider. I also have a clear understanding that both myself and the provider are accepting the potential risks of touch based and holistic therapies, and I will not hold the provider, their agents, employers or affiliates liable if I acquire COVID-19.
• The Peaceful Spirit cancellation policy for all treatments is as follows: A minimum of 24 hour’s notice of cancellation must be given (48 hours preferred) or I will be billed the full fee for the missed appointment.

If you are currently scheduled with our chiropractor or plan to become a chiropractic patient in the future, please complete this form.

Dear Patient: Please feel free to discuss any questions or concerns with the Doctor before signing this consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above.

I have the option to discuss with the doctor and/or with other clinic personnel the purpose and benefits of the chiropractic adjustment and other treatments outlined below. Alternatives to treatment can be reviewed.

Though chiropractic adjustments and treatments are usually beneficial and rarely cause any problem, I understand and informed that there are some risks to treatment. Risks include, but are not limited to, sprains, fractures, dislocations, disc injury, and stroke.

I understand that I may be receiving the following treatment:

• Chiropractic adjustments (manually, or by adjusting instruments)
• lectric muscle stimulation
• Ultrasound
• Myotherapy-soft tissue therapies
• Rehabilitative Exercise
• Other modalities

Therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. Any question that I have had regarding my care has been answered to my satisfaction. I consent to the proposed treatment.

If you are currently scheduled with our chiropractor or plan to become a chiropractic patient in the future, please complete this form.

Dear Patient: Please feel free to discuss any questions or concerns with the Doctor before signing this consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible).

I have the option to discuss with the doctor and/or with other clinic personnel the purpose and benefits of the chiropractic adjustment and other treatments outlined below. Alternatives to treatment can be reviewed.

Though chiropractic adjustments and treatments are usually beneficial and rarely cause any problem, I understand and informed that there are some risks to treatment. Risks include, but are not limited to, sprains, fractures, dislocations, disc injury, and stroke.

I understand that I may be receiving the following treatment:

• Chiropractic adjustments (manually, or by adjusting instruments)
• Electric muscle stimulation
• Ultrasound
• Myotherapy-soft tissue therapies
• Rehabilitative Exercise
• Other modalities

I understand that chiropractic, like any other form of health care, is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. Any question that I have had regarding my care has been answered to my satisfaction. I consent to the proposed treatment.