Consent Form

I,  , hereby voluntarily request to receive clinical services from Scott Turpin of Alpine Eastern Medicine LLC. I consent that these services may include, but are not limited to, acupuncture, moxibustion, nutritional/dietary counseling, herbology, Tui-Na massage, cupping and other related services. I acknowledge that no guarantees have been made to me as to the effect of such care.

I have been informed that treatment may occasionally result in bruising, soreness, burns or discomfort, and that every precaution will be taken to protect me. I understand that prior to any procedure, I will receive an explanation of its nature and purpose, and any probable risks involved. I also understand that I may refuse any and all services at any time.

I do not expect the acupuncturist to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist's judgment during the course of treatment. I further acknowledge that none of these services are to be understood by me as the diagnosis or treatment of disease, but rather as an aid to balancing my energy and improving my general wellness.

I understand that this clinic holds Traditional Chinese Medicine to be complementary to orthodox medical treatment, unless contrary medical advice is given. I am advised that if I am sick, I should consult my doctor.

I recognize that I am responsible for my health and well being, and that it is my duty to be an informed partner in the care I receive from Scott Turpin of Alpine Eastern Medicine LLC. To this end, I will secure the self-knowledge that I need in order to work effectively with my practitioner.

I understand that standard appointments are booked for hour-long sessions, and that 24-hour notice is required for cancellations. If proper notice is not given, I understand that I will be required to pay a cancellation fee at the rate of a normal office visit.

I understand that payment is due at the time of service. Should I have a complaint or grievance regarding services, I will speak with my clinician. I understand the clinical and administrative staff may review my medical records and lab reports, but that all records will be kept confidential, including address and contact information.

I have read the above consent. I have had an opportunity to ask questions about its content and by signing below I agree to the above procedures and consent to treatment. My signature below grants Scott Turpin of Alpine Eastern Medicine LLC, or his staff, permission to contact me by phone regarding my appointment and by mail or email with information about the clinic.