Common use of Retroactive Effect Clause in Contracts

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example), emergency treatment), ) patient should initial here. here _. Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE PRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE X (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) OFFICE SIGNATURE X (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massageMassage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicinemedicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE AAC-FED A2004 ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . below: Effective as of the date of first professional medical services. Patient’s Initials If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected af- fected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIALTRAIL. SEE ARTICLE 1 OF THIS CONTRACT. Phoenix Advanced Medical Associates 0000 Xxxxxxx Xxxxxx Xx., Xxxxx 00, Xxxxxx Xxxxx, XX 00000 Phone: 000-000-0000 Fax: 000-000-0000 Xxxxxx Xxxxx, M.D. Patient (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) Physician Print Name Patient’s Agent or Representative (Date) OFFICE SIGNATURE X Acknowledgement of Privacy Policy I have been advised of Phoenix Advanced Medical Associates Office Privacy Policy. ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope A copy of the practice Policy is avail- able upon request to review or retain. Insurance Authorization I authorize release of acupuncture on me (any medical or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories information necessary to this form or notall my insurance companies. I understand I am responsible for my billing including deductible and co-pays. I authorize my doctor to act as my agent in help- ing me obtain payment from my insurance companies. I authorize payment directly to the provider. Lab Testing It may be necessary for the office to do additional tests which will be sent to an outside lab. The fees for these tests are separate from the fees for your office visit, and are payable directly to the lab by you. If we have your current insurance information on file, we will forward that methods of treatment may includeinformation to the lab. If your claim is denied, but the lab will send you a xxxx for their services. We are not limited toaffiliated with the lab billing. Copy Records Fee Due to increased paperwork in the office, acupuncturewe are no longer able to copy records on a courtesy basis. Payment is required prior to picking up copied records , moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counselingor when copied records are picked up. I understand that the herbs may need to be prepared A signed Records Release Form is required and the teas consumed according copy fee is 25 cents per page. Postage will be additional if records are mailed, payable prior to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbsmailing records. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, read and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reportsabove information. Patient Signature: Date: PATIENTS INFORMATION Who referred you to this office? Other MD’s: q Mr q Miss q Mrs. q Ms. Last Name: First Name: MI: Is this your legal name? q Yes q No If not, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(swhat is your legal name? (Former name): Marital status (Circle One) for which I seek treatment. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)Single / Mar / Div / Sep / Wid

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. here _. Effective as of the date of first professional services. If any provision of this the Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE (or Patient Representative) (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO ARBITRATION AGREEMENT AND INFORMED CONSENT, PAGE 2 OF 2 œ PLEASE SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT BOTH SIDES I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed licensed/certified acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, bleeding, Gua- Sha, electrical stimulation, Tui-Na (Chinese Oriental massage), Chinese Oriental 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 or in writing. The herbs may have an unpleasant smell or and/or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 cuppingcupping and Gua-Sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses disposable sterile disposable needles and maintains a clean and safe environment. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or or Patient Representative) OFFICE SIGNATURE X (Date) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE AAC-FED A2004 ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: Xxxxx Xxxx, ND LAc (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this the Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected effected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) DATE OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE DATE CHIROPRATIC INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments chiropractic adjustments and other procedures within the scope chiropractic procedures, including various modes of the practice of acupuncture physical therapy and diagnostic x‐rays, and supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist doctor of chiropractic indicated below and/or other licensed acupuncturists doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up back‐up for the acupuncturist doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that methods results are not guaranteed. I understand an am informed that, as in the practice of treatment may includemedicine and like all other health modalities, results are not guaranteed, and there is no promise of cure. I further understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but are not limited to, acupuncturefractures, moxibustiondisk injuries, cuppingstrokes, electrical stimulationdislocations and sprains, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff doctor to be able to anticipate and explain all possible risks and complications of treatmentcomplications, and I wish to rely on the clinical staff doctor to exercise judgment during the course of treatment the procedure which the clinical staff thinks doctor feels at the time, based upon the facts then known, is in my best interest. I further understand that results there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not guaranteedlimited to, self‐administered, over the counter analgesics and rest; medical care with prescription drugs such as anti‐inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the clinical right to a second opinion and administrative staff may review to secure other opinions if I have concerns as to the nature of my patient records symptoms and lab reports, but all my records will be kept confidential and will not be released without my written consenttreatment options. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, consent. I have been told about the risks and benefits of acupuncture and other procedures, and have also had an opportunity to ask questionsquestions about its content, and by singing below I agree to the above‐named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any my future condition(s) for which I seek treatment. ACUPUNCTURIST CHIROPRACTOR NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)XXXXXXXXX XXXXXXXX, DC, DICCP, DiHom

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of a s the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Date) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO PLEASE SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE ALSO ARBITRATION AGREEMENT AND INFORMED CONSENT TO TREAT CONSENT, PAGE 2 OF 2 – PLEASE SIGN BOTH SIDES I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other their office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Oriental massage), Chinese Oriental 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Date) (Indicate relationship if signing for patient) OFFICE SIGNATURE (Date)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for exampleincluding, but not limited to, emergency treatment), ) patient should initial here. . below: Effective as of the date of first professional medical services. .Patient or Patient’s Representatives Initials If any provision of this Arbitration Agreement arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreementarbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. By: Date By: Date Physician’s or Duly Authorized Representative’s Signature Patient’s Signature Print or Stamp Name of Physician or representative Print Patient’s Name By: Signature of Translator (Dateif applicable) PATIENT SIGNATURE X (Or Date By: Patient’s Representative Signature Date Print Name and Relationship to Patient Representative) (Indicate relationship if signing Examples of Disclosures for patient) (Date) OFFICE SIGNATURE X Treatment, Payment and Health Operations We will use your health information for treatment. ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and For example: Information obtained by a nurse, physician, or other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, your health care team will be recorded in your record and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff used to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during determine the course of treatment which that should work best for you. Your physician will document in your record his or her expectations of the clinical staff thinks at members of your health care team. Members of your health care team will then record the time, based upon the facts then known, is in my best interestactions they took and their observations. I understand In that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to meway, the above consent physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you're discharged from this hospital. We will use your health information for payment For example: A xxxx may be sent to you or a third-party payer. The information on or accompanying the xxxx may include information that identifies you, have been told about the risks and benefits of acupuncture and other as well as your diagnosis, procedures, and have had supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an opportunity effort to ask questionscontinually improve the quality and effectiveness of the healthcare and service we provide. I intend this consent form Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to cover our business associate so that they can perform the entire course of treatment job we've asked them to do and xxxx you or your third-party payer for my present condition and for any future condition(s) for which I seek treatmentservices rendered. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)To protect your health information, however, we require the business associate to appropriately safeguard your information.

Retroactive Effect. If patient intends this agreement to cover services rendered before the date that it is signed (for example, emergency treatment), patient should initial here. here . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X DATE (Or Patient Representative) (Indicate relationship Relationship if signing Signing for patient) (Date) Patient: OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED DATE CONSENT TO TREAT I hereby request CARE You are the decision maker for your health care. Part of our role is to provide you with the information to assist you in making informed choices. This process is often referred to as “informed consent” and consent involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the performance care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use4 our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of acupuncture treatments an adjustment include restoring normal joint motion, reducing swelling and other procedures within inflammation in a joint, reducing pain in the scope joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: Muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, xxxxx and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the practice artery that may cause the development of acupuncture on me a thrombus (or on clot) with the patient named belowpotential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, for whom I am legally responsible) healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or arterial dissection have been associated with or serving over 72 everyday activities such as backsneezing, driving, and playing tennis. Arterial dissections occur in 3-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, 4 of every 100,000 people whether signatories to this form they are receiving health care or not. I Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/per one million persons/year and risk of death has been estimated as 104 per one million users. It is also important that you understand that methods there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of treatment these approaches already. These options may include, but are not limited to: Self-administered care, acupunctureover-the-counter pain relievers, moxibustionphysical measures and rest, cuppingmedical care with prescription drugs, electrical stimulationphysical therapy, Tui-Na (Chinese massage)bracing, Chinese herbal medicineinjections, and nutritional counselingsurgery. I understand that Lastly, you have the herbs may need right to be prepared a second opinion and the teas consumed according to the instructions provided orally secure other opinions about your circumstances and in writinghealth care as you see fit. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent consent. I appreciate that it is no possible to treatment, consider every possible complication to care. I have been told about the risks and benefits of acupuncture and other procedures, and have also had an opportunity to ask questionsquestions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. I, , have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, and by signing below I agree to the above-above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(sconditions(s) for which I seek treatment. ACUPUNCTURIST NAMEPatient’s Name: (Signature: Date Parent/Guardian: Signature: Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENTS GUARDIAN SIGNATURE AND RELATIONSHIP x (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) OFFICE SIGNATURE (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE AAC-FED INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice practice, for the condition of acupuncture GERD in infants and small children, on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist provider indicated below and/or other licensed acupuncturists providers who now or in the future treat me while employed by, working or associated with or serving as back-back- up for the acupuncturist medical provider named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupunctureH2 blocker therapy, moxibustionantacid therapy, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicineproton pump inhibitor therapy, and nutritional in some instances feeding therapy, informative counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs, infant reflux coaching. I have been informed that acupuncture is methods of treatment are generally a generally safe method of treatment, but that it they may have some side effects, including bruisingincluding, numbness or tingling near the needling sites that may last a few daysbut not limited to, gas, spitting up, diarrhea, rash, constipation, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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 environmentoverall digestive discomfort. I understand that while this document describes the major some of the risks of treatment, other side effects and risks may occur. The herbs occur and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe informed myself of the risks involved in the practice of Chinese Medicine, although some may be toxic treatments described in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnantthis agreement. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other the offered procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAMEPROVIDERS NAMES: XX. XXXXXXXX XXX PRINCE XXXXXXX X XXXXXXXX PHARM D. XXXX XXXXXXXX XXXXXXXX DATE PATIENTS LEGAL GUARDIAN SIGNATURE (DateAND RELATIONSHIP TO PATIENT) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist. I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with with, or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. 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 that it may have some side effects, including not limited to: bruising, ; numbness or tingling near the needling sites that may last a few days, ; and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am or nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. Some possible side effects of taking herbs are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; and tingling of the tongue. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that 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). I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. I understand that there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit. By voluntarily signing below, I show confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. PATIENT NAME: ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE Metta Acupuncture 0000 Xxxxx Xx ! Xxxxxxx, XX 00000 000-000-0000 ! xxxxx.xxx.lac@xxxxx.xxx ! xxx.xxxxx-xxxxxxxxxxx.xxx Consent Form for Acupuncture Treatment I, hereby authorize Xxxxx Xxxxxxxx LAc (the Acupuncturist) to perform procedures as necessary to facilitate diagnosis and treatment. Treatment may include: • Acupuncture: insertion of special sterilized needles through the skin into underlying tissues at specific points on the surface of the body. • Cupping: a technique to relieve symptoms in which cups made of glass or other materials are placed on the skin with a vacuum created by heat or other device. • Dermal friction (Gua Sha): rubbing on an area of the body with a blunt, round instrument. • Dietary advice: based on traditional Chinese medical theory. • Electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians. • Infrared therapy: radiant heating using electricity. • Moxa/moxibustion: direct/indirect burning of herbs/herbal blends on an acupoint/meridian using stick, string, Tiger warmer, cone, or ball moxa. • Shiatsu/Tuina: Japanese and Chinese massage used to treat a wide variety of common disharmonies. Risks of Treatment: Acupuncture has been shown to be very safe. However, there are some uncommon but potential risks. These potential risks may include but are not limited to: " Discomfort during and after the insertion of a needle " “Needle sickness” (dizziness, fainting, nausea) " Localized bruising or swelling from needles or cupping " Xxxxx or blisters with the use of moxa " Possible, temporary aggravation of symptoms that existed prior to treatment " Broken needle " Possible organ puncture leading to Infection (very rare) Special Situations: You must inform Xxxxx Xxxxxxxx, X.Xx. if you have severe bleeding disorders, are prone to seizures, wearing a pacemaker or other electronic medical device. All female patients must notify the Acupuncturist or one the staff if they are or believe they may be pregnant. CONSENT TO TREAT I consent to the performance of acupuncture and other procedures for purposes of diagnosis and treatment. I understand that I am free to withdraw my consent and that I may stop treatment or any procedure at any time. I understand that my signature on this form indicates that I have read and understand the preceding information regarding my treatment, including potential risks and benefits as described above. I understand that if I have any questions about this information, I will ask Xxxxx Xxxxxxxx, X.Xx. Signature of Patient Date Signature of Patient’s Representative or Legal Guardian Date

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) OFFICE SIGNATURE X (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE AAC-CA ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, TuiTiu-Na (Chinese massage), Chinese 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request NCC-FED C2004 Informed Consent to Care You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and consent involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the performance care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of acupuncture treatments an adjustment include restoring normal joint motion, reducing swelling and other procedures within the scope of the practice of acupuncture on me (or on the patient named belowinflammation in a joint, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or reducing pain in the future treat me while employed byjoint, working and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, xxxxx and/or scarring from electrical stimulation and from hot or associated with or serving as back-up for the acupuncturist named belowcold therapies, including those working at but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the clinic or office listed below or any other office or clinic, wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people whether signatories to this form they are receiving health care or not. I Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. It is also important that you understand that methods there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of treatment these approaches already. These options may include, but are not limited to: self-administered care, acupunctureover-the-counter pain relievers, moxibustionphysical measures and rest, cuppingmedical care with prescription drugs, electrical stimulationphysical therapy, Tui-Na (Chinese massage)bracing, Chinese herbal medicineinjections, and nutritional counselingsurgery. I understand that Lastly, you have the herbs may need right to be prepared a second opinion and the teas consumed according to the instructions provided orally secure other opinions about your circumstances and in writinghealth care as you see fit. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent consent. I appreciate that it is not possible to treatment, consider every possible complication to care. I have been told about the risks and benefits of acupuncture and other procedures, and have also had an opportunity to ask questionsquestions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent form to cover the entire course of treatment care from all providers in this office for my present condition and for any future condition(s) for which I seek treatmentchiropractic care from this office. ACUPUNCTURIST NAMEPatient Name: (Signature: Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient): Parent or Guardian: Signature: Date:

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 2 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) Date (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Oriental massage), Chinese Oriental 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand that the clinical health care providers and administrative staff affiliated with Light of Heart Acupuncture and Herbs Inc., and their affiliates and partners may review access my patient records and records, lab reports, financial information, and other personal information in order to provide supporting services, including but not limited to billing, filing insurance claims, managing my patient records, analyzing and evaluating my treatments, coordinating cooperation among health care providers, contacting me about follow-up appointments and possible treatment options or alternatives that may benefit me, contacting my emergency contacts in case of an emergency, disclosing my information to the government authorities as required by federal, state, or local law, but all my records will be otherwise kept confidential and will not be released to other entities without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAMEPATIENT FINANCIAL RESPONSIBILTY FORM The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for the medical and other services rendered to the patient and/or products purchased by the patient. We are pleased to assist the patient by filing insurance claims and billing his/her insurance providers, if we determine at our sole discretion that the patient’s insurance policy is acceptable to us. The patient is required to provide us the most correct and updated information about his/her insurance, and will be responsible for any charges incurred if the information provided is not correct or updated. The patient is responsible for the payment of co-pays, coinsurance, deductibles, and all other procedures, treatments, services, and/or products not covered by his/her insurance plan. Payment is due at the time of services and/or sales. If the patient’s insurance policy pays less than our fees, the patient is required to pay the difference within ten (10) business days upon our verbal or written notice. It’s understood that our fees for cash-payment patients is discounted from our regular fees. When we xxxx the patient’s insurance provider, we apply the regular fees. It’s understood that the payment from the patient’s insurance provider should be sent and payable to us. From time to time, the insurance providers might mistakenly send the payment to the patient directly. When it happens, it is the patient’s responsibility to contact us promptly and return the payment to us within ten (10) business days. Patients may incur, and are responsible for the payment of additional charges, including but not limited to: (Date) Charge for returned checks Charge for extensive phone consolations and/or after-hours phone calls requiring diagnosis, treatment, and/or prescription. Charge for extensive form completion. Charge of missed appointments without 24 hours advance notice. Charge for the copying and distribution of patient medical records. Any costs associated with collection of patient balances. By my signature below, I hereby authorize the health care providers and staff associated with Light of Heart Acupuncture and Herbs Inc., and/or their affiliates and partners to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payers, and/or other health care providers and/or entities required to participate in my care. By my signature below, I hereby authorize assignment of financial benefits directly to Light of Heart Acupuncture and Herbs Inc., their affiliates and partners, and/or any associated health care entities for serviced rendered as allowable under standard third contracts. I understand that I am financially responsible for charges not covered by this assignment.. By my signature below, I authorize Light of Heart Acupuncture and Herbs Inc., and their affiliates and partners to securely store my credit card information and only charge it should I have an outstanding balance or any leftover balance from a processed claim in the future. I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THIS FORM: PATIENT SIGNATURE X (Or Patient Representative) Date (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request NCC-CA C2007 Informed Consent to Care You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and consent involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the performance care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of acupuncture treatments an adjustment include restoring normal joint motion, reducing swelling and other procedures within inflammation in a joint, reducing pain in the scope joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, xxxxx and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the practice artery that may cause the development of acupuncture on me a thrombus (or on clot) with the patient named belowpotential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, for whom I am legally responsible) healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or arterial dissections have been associated with or serving over 72 everyday activities such as backsneezing, driving, and playing tennis. Arterial dissections occur in 3-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, 4 of every 100,000 people whether signatories to this form they are receiving health care or not. I Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users. It is also important that you understand that methods there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of treatment these approaches already. These options may include, but are not limited to: self-administered care, acupunctureover-the-counter pain relievers, moxibustionphysical measures and rest, cuppingmedical care with prescription drugs, electrical stimulationphysical therapy, Tui-Na (Chinese massage)bracing, Chinese herbal medicineinjections, and nutritional counselingsurgery. I understand that Lastly, you have the herbs may need right to be prepared a second opinion and the teas consumed according to the instructions provided orally secure other opinions about your circumstances and in writinghealth care as you see fit. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent consent. I appreciate that it is not possible to treatment, consider every possible complication to care. I have been told about the risks and benefits of acupuncture and other procedures, and have also had an opportunity to ask questionsquestions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent form to cover the entire course of treatment care from all providers in this office for my present condition and for any future condition(s) for which I seek treatment. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)chiropractic care from this office.

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE AAC-FED A2004 ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or and /or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for exampleincluding, but not limited to, emergency treatment), ) patient should initial here. . below: Effective as of the date of first professional services. medical services Patient’s or Patient Representative’s Initials If any provision of this Arbitration Agreement arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreementarbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. By: Physician’s or Authorized Representative’s Signature (Date) PATIENT SIGNATURE X (Or ORTHOPAEDIC SURGERY SPECIALISTS & AFFILIATED ASSOCIATES Print or Stamp Name of Physician, Medical Group, or Associate Name By: Patient’s or Patient Representative) (Indicate relationship if signing for patient) ’s Signature (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request By: Print Patient’s Name By: (if Representative, Print Name and consent Relationship to Patient) A signed copy of this document is to be given to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me Patient. Original is to be filed in Patient’s medical records. (or on the patient named below, for whom I am legally responsible01-16) by the acupuncturist indicated below and/or other licensed acupuncturists who now or MEDICAL QUESTIONNAIRE 0000 XXXX XXXXXXX XXXXXX • SUITE 116 • BURBANK • CA • 00000-0000 • PHONE (000) 000-0000 • FAX (000) 000-0000 GENERAL Name Last Name First Name M.I. Today’s Date (MM/DD/YYYY) / / Gender Male Female Height Weight Age Which is your dominant hand? Left Right Referring Doctor & Phone Primary Care Doctor & Phone Have you been discharged from an inpatient facility in the future treat me while employed bypast 30 days? If yes: What was your date of discharge? Were any of your medications changed? CURRENT PROBLEM What part of your body are you being seen for today? Which side? (if applicable) Left Right What is the goal of your appointment today? Pain Management Better Function Better Appearance Return to Work Return to Play Other: How did the problem develop? When did the problem start: Over Time (Duration: ) Injury (Date of Injury: ) Is this work related? Yes No Have you noticed any weakenss? Yes No If yes, working or associated with or serving as backexplain: What other symptoms do you have? Do your symptoms limit your ability to work? Yes No If yes, explain: Do your symptoms affect your activities of daily living? Yes No If yes, explain: Do your symptoms keep you awake at night? Yes No What treatments have you tried? Injection Physical Therapy Chiropractic Medication: Other: Have any treatments helped? Yes No Please explain: How many street blocks can you walk? Do you use a walking device? Cane Crutches Xxxxxx Wheel Chair Not Applicable; Don’t use a walking device Describe how you use stairs: Place one foot per step Place both feet on step before proceeding to next Not Applicable; Don’t use stairs MEDICAL QUESTIONNAIRE 0000 XXXX XXXXXXX XXXXXX • SUITE 116 • BURBANK • CA • 00000-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui0000 • PHONE (000) 000-Na 0000 • FAX (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 000) 000-0000 MEDICAL HISTORY: LIST ALL Medical problems: Medications: Supplements: Surgeries: Drug allergies (include spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAMEreaction): SOCIAL HISTORY Marital Status: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)Single Married Domestic Partner Divorced Widowed Name: Hobbies / Interests: Occupation:

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X DATE (Or Patient Representative) (Indicate relationship if signing for patient) (Dateor patient representative) OFFICE SIGNATURE X . DATE (ALSO SIGN THE INFORMED CONSENT ON THE REVERSE SIDE SIDE) ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx and/or scarring are a potential risk of moxibustion and or cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment judgement during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)DATE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective Ef- fective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions pro- visions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X patIent naMe patIent sIGnature (Or Patient RepresentativepatIent representatIve) Date relatIOnshIp (Indicate relationship if signing for patientIF sIGnInG FOr patIent) (Date) OFFICE SIGNATURE X MOxa acupuncture & herbs sIGnature Date Also sign the Informed Consent form on the next page. ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists acupunc- turists who now or in the future treat me while employed by, working or associated with or serving serv- ing as back-up for the acupuncturist named belowbe- low, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustionmox- ibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant un- pleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption con- sumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruisingbruis- ing, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx and/or scarring are a potential risk of moxibustion and cupping, or when treatment treat- ment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another an- other possible risk, although the clinic uses sterile ster- ile disposable needles and maintains a clean and safe environment. I understand that while this document describes de- scribes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional nutri- tional supplements (which are from plant, animal and mineral sources) that have been recommended recom- mended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reportsre- ports, but all my records will be kept confidential confiden- tial and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedurespro- cedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition condi- tion and for any future condition(s) for which I seek treatment. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X acupuncturIst naMe Xxxxx Xxxxxxxxxxx mtom, lac patIent sIGnature (Or Patient RepresentativepatIent representatIve) Date relatIOnshIp (Indicate relationship if signing for patientIF sIGnInG FOr patIent)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. __________. Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the a right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Patient Signature__________________________________________________________________________________ Date __________________ (Date) PATIENT SIGNATURE X (Or or Patient Representative) (Representative – Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . PLEASE SIGN SECOND PAGE ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on in the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Oriental massage), Chinese Oriental 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: Patient Signature__________________________________________________________________________________ Date __________________ (Date) PATIENT SIGNATURE X (Or or Patient Representative) (Representative – Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE X (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) OFFICE SIGNATURE X (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, TuiTiu-Na (Chinese massage), Chinese 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 e fect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: PATIENT SIGNATURE (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . NCC-CA ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE CHIROPRACTIC INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and other procedures within the scope of the practice of acupuncture any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist doctor of chiropractic indicated below and/or other licensed acupuncturists doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that methods and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of treatment may includechiropractic there are some risks to treatment, including, but are not limited to, acupuncturemuscle spasms for short periods of time, moxibustionaggravating and/or temporary increase in symptoms, cuppinglack in improvement of symptoms, electrical stimulationfractures, Tui-Na (Chinese massage)disc injuries, Chinese herbal medicinestrokes, dislocations and nutritional counselingsprains. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff doctor to be able to anticipate and explain all possible risks and complications of treatmentcomplications, and I wish to rely on the clinical staff doctor to exercise judgment during the course of treatment the procedure which the clinical staff thinks doctor feels at the time, based upon the facts then known, is in my best interestinterests. I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment. I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that results are not guaranteedI have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, consent. I have been told about the risks and benefits of acupuncture and other procedures, and have also had an opportunity to ask questionsquestions about its content, and by signing below I agree to the above-named procedures. 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. ACUPUNCTURIST NAMEName of Patient: Signature of Patient: Name Printed of Guardian/Parental and Relationship to Patient: Guardian/Parental Signature: Date: Doctor of Chiropractic Name: Signature of Doctor of Chiropractic: Date: OPTIONAL Arbitration Information Packet (DateRequired with Elite Program) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing C h i r o S e c u r e Protecting You From Nuisance Claims Allied Professionals Insurance Company, a Risk Retention Group, is the only malpractice carrier that takes a pro-active approach to limiting your exposure to nuisance claims. They provide you with the paperwork needed to ensure your patient files are protected from attorneys attempting to attack you on some legal technicality. As a participant in the Allied “Elite” program, doctors utilize an arbitration agreement and informed consent form as a standard part of their intake paperwork. This effectively takes doctors out of the line of fire of nuisance suits. In fact, this system works so well that participants in the “Elite” program get sued eight times less often than the average in the profession. Good communication with patients is key to limiting your malpractice exposure. That communication needs to be balanced and cover all the bases. The “Elite” program supplemental intake paperwork does just this, while at the same time meeting all the legal requirements pertinent to your practice. By taking this step with your patients, you begin to build the trust and confidence needed for patient)a lasting relationship. Since 1986, Allied has been working to keep its doctors out of the court room, and attorneys out of the practice of medicine. Allied’s proven approach creates a safe environment for our doctors, so they can better focus on providing quality patient care. By keeping the cost of malpractice insurance down, doctors are able to continue to provide that care affordably.

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the a right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Patient Signature Date (Date) PATIENT SIGNATURE X (Or or Patient Representative) (Representative – Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . PLEASE SIGN SECOND PAGE ALSO ARBITRATION AGREEMENT AND INFORMED CONSENT, PAGE 2 OF 2 – PLEASE SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT BOTH PAGES I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on in the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up back‐up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na Tui‐Na (Chinese Oriental massage), Chinese Oriental 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. The herbs may have be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: Patient Signature Date (Date) PATIENT SIGNATURE X (Or or Patient Representative) (Representative – Indicate relationship if signing for patient)

Retroactive Effect. If patient Patient/Client intends that this agreement to Arbitration Agreement cover services rendered before the date it that this Agreement is signed executed (for exampleincluding, but not limited to, emergency treatment), patient Patient/Client should initial here. . below: Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid medical services Patient/Client’s or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. Patient/Client Representative’s Initials NOTICE: BY SIGNING THIS CONTRACT, AGREEMENT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE AND/OR ANY ISSUE RELATED TO THIS AGREEMENT BE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACTAGREEMENT. Printed Name of Patient/Client, or Legal Guardian of Patient/Client Signature of Patient/Client, or Legal Guardian of Patient/Client Date If signed by other than Patient/Client, indicate relationship: If Patient/Client is unable to sign, then verbal consent is given. Specify Reason: PHYSICIAN’S AGREEMENT TO ARBITRATE In consideration of the foregoing execution of this Patient/Client-Provider Arbitration Agreement, I likewise agree to be bound by the terms set forth in this Agreement. Printed Name of Witness Signature of Witness Date NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. OAK HEALTH CENTER, A MEDICAL CORPORATION IS REQUIRED BY LAW TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing “PHI”). The PHI constitutes information created or noted by Oak Health Center that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for patient) (Date) OFFICE SIGNATURE X such health care. ALSO SIGN We are required to provide you this notice about our privacy procedures. This notice must explain when, why, and how we would use and/or disclose your PHI. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice. PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. However, we are always legally required to follow the privacy practices described in this notice. Please note that we reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to PHI already on file with us. Before we make any important changes to our policies, this notice will be updated and a copy will be available to you upon request. HOW WE WILL USE AND DISCLOSE YOUR PHI We will use and disclose your PHI for different reasons. Some of the uses of disclosure will require your prior written consent, others, however will not. Please find below the various categories, and examples, for our use and disclosures. USE AND DISCLOSURES RELATED TO TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS DO NOT REQUIRE YOUR PRIOR WRITTEN CONSENT. WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR CONSENT FOR THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request FOLLOWING REASONS. For treatment- We may disclose your PHI to physicians, psychiatrists, psychologists, and consent other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychologist or therapist is treating you, we may disclose your PHI in order to coordinate your care. For Health Care Operations- We may disclose your PHI to facilitate the efficient and correct operation of our practice. Examples: Quality control where we might use your PHI in the evaluations of the quality of health care services that you have received or to evaluate the performance of acupuncture treatments the health care professionals who provided you with these services. We may also provide your PHI to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws. To obtain payment for treatment- We may use and disclose your PHI to xxxx and collect payment for the treatment and services we provide you. Example: We might send your PHI to your insurance company or health plan provider in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for our office. Other disclosures- Examples: Your consent is not required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain), and we think that you would consent to such treatment if you could, we may disclosure your PHI. Certain other procedures within uses and disclosures do not require your consent. We may use and/or disclose you PHI without your consent or authorization for the scope following reasons: The following list is a compilation of federal and California laws.  When disclosure is required by federal, state, or local law, judicial board, administrative proceedings or law enforcement. Example: We may make a disclosure to the appropriate officials when a law requires us to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.  If disclosure is completed by a party to a proceeding before a court or an administrative agency pursuant to its lawful authority.  If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.  If disclosure is compelled by the Client or the Client’s representative pursuant to California Health and Safety Codes or to corresponding federal statutes or regulations, such as the Privacy Rule that requires this Notice.  To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person of the practice of acupuncture on me (public.  If disclosure is compelled or on the patient named below, for whom I am legally responsible) permitted by the acupuncturist indicated below and/or other licensed acupuncturists who now fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.  If disclosure is mandated by the California Child Abuse and Neglect Reporting Law. For example: If we have a reasonable suspicion of child abuse or neglect.  If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting Law. For example: If we have a reasonable suspicion of elder abuse or dependent adult abuse.  If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.  For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.  For health oversight activities. Example: We may be required to provide information to assist the government in the future treat me while employed bycourse of an investigation or inspection of a health care organization or provider.  For specific government functions. Examples: We may disclose PHI of military personnel and veterans under certain circumstances. Also, working we may disclose PHI in the interest of national security, such as protecting the President of the United States or associated assisting with intelligence operations.  For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.  For workers’ compensation purposes. We may provide PHI in order to comply with Workers’ Compensation laws.  Appointment reminders and health related benefits or serving as back-up services. Examples: We may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.  If an arbitrator or arbitration panel compels disclosure. If disclosure is required pursuant to subpoena duces tecum (e.g., a subpoena for the acupuncturist named below, including those working at the clinic or office listed below mental health records) or any other office provision authorizing disclosure in a proceeding before an arbitrator or clinicarbitration panel.  We are permitted to contact you, whether signatories without your prior authorization, to this form provide appointment reminders or notinformation about alternative or other health-related benefits and services that may be of interest to you. I understand  If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess our compliance with HIPAA regulations.  If disclosure is otherwise specifically required by law. Certain uses and disclosures require you to have the opportunity to object. Disclosure to family, friends or others. We may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations. Other uses and disclosures require your prior written authorization. In any other situation not described above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that methods of treatment may includeauthorization, but are not limited toin writing, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na to stop any future uses and disclosures (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand assuming that the herbs may need to be prepared and the teas consumed according we haven’t taken any action subsequent to the instructions provided orally original authorization) of your PHI by us. YOUR RIGHTS REGARDING YOUR PHI The right to inspect and obtain copies of your PHI. In general, you have the right to see your PHI that is in our possession or to get copies of it. However, you must request it in writing. The herbs If we do not have your PHI, but we know who does, we will advise you how you can obtain it. You will receive a response from us within thirty (30) days of our receipt of your written request. Under certain circumstances, we may feel we must deny your request. If so, we will respond in writing the reasons for denial. We will also explain your right to have an unpleasant smell our denial reviewed. If you ask for copies of your PHI, we will charge you not more than $.25 per page. We may see fit to provide you with a summary or taste. I will immediately notify a member explanation of the clinical staff PHI, but only if you agree to it, as well as to the cost, in advance. The right to request limits on uses and disclosures of any unanticipated your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or unpleasant effects associated with permitted to make. The right to choose how we send your PHI to you. It is your right to ask that your PHI be sent to you at an alternate address (e.g., sending information to your work address rather than to your home address) or by an alternate method (e.g., by e-mail or by regular mail). We are obliged to agree to your request providing that we can give you the consumption PHI, in the format you requested without undue inconvenience. The right to get a list of the herbsdisclosures we have made. I You are entitled to a list of disclosures of your PHI that we have been informed that acupuncture is a generally safe method made. The list will not include uses of disclosures to which you have already consented, i.e. those for treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx and/or scarring are a potential risk of moxibustion and cuppingpayment, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriagehealth care operations, nerve damage and organ puncturesent directly to you, 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 occuror to your family. The herbs and nutritional supplements (which are from plantlist will not include disclosures made for national security purposes, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicineto corrections or law enforcement personnel, although some may be toxic in large dosesor disclosures made before November 17, 2006. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nauseaAfter November 17, gas2006, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my disclosure records will be kept confidential held for six (6) years. We will respond to your request for an accounting of disclosures within sixty (60) days of receiving your request. The list we give you will include disclosures made in the previous six (6) years (the first six year period being 2006-2012) unless you indicate a shorter period. The list will include the date of disclosure, to whom PHI was disclosed (including the address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one (1) request in the same year, in which case we will charge a reasonable amount for each additional request. The right to amend or revise your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be in writing. You will receive a response within sixty (60) days of our receipt of your request. We may deny your request, in writing, if we find that, (a) the PHI is correct and complete, (b) forbidden to be disclosed, (c) not part of our records or (d) written by someone who is not a part of our practice. Our denial must be released without my in writing and must state the reason for denial. It must also explain your right to file a written consentstatement objecting to the denial. By voluntarily signing belowIf you do not file a written objection, I show you still have the right to ask that I your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have readbeen made, and we will advise all others who need to know about the change(s) to your PHI. The right to get this notice by E-mail. You have the right to get this notice by E-mail. You have the right to request a copy as well. QUESTIONS AND COMPLAINTS If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact us at our address above. If, in your opinion, we may have had read violated your privacy rights, or if you object to mea decision we made about access to your PHI, you are entitled to file a complaint with us at the above consent address listed above. You may also send a written complaint to treatmentthe Secretary of the Department of Health and Human Services, have been told about the risks and benefits of acupuncture and other procedures000 Xxxxxxxxxxxx Xxxxxx X.X. Xxxxxxxxxx, and have had an opportunity to ask questionsX.X. 00000. THIS NOTICE IS EFFECTIVE AS OF MARCH 1, 2016. I intend this HAVE READ, AND FULLY UNDERSTAND, THE ABOVE INFORMATION REGARDING MY PRIVACY RIGHTS. Printed Name of Patient/Client, or Legal Guardian of Patient/Client Signature of Patient/Client, or Legal Guardian of Patient/Client Date If signed by other than Patient/Client, indicate relationship: If Patient/Client is unable to sign, then verbal consent form is given. Specify Reason: Printed Name of Witness Signature of Witness Date APPOINTMENT CANCELLATION POLICY We strive to cover provide excellent mental health care to you, your family and all of our patients/clients. In order to do so effectively and efficiently, we have developed an appointment system that sets aside ample time for a patient/client. No-Shows and late cancellations inconvenience those individuals who need access to care in a timely manner. In an effort to reduce the entire course number of treatment for my present condition such occurrences, we have implemented an Appointment Cancellation Policy and for any future condition(s) for which I seek treatmentit is effective immediately. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)Our policy is as follows:

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE Metta Acupuncture 0000 Xxxxx Xx • Madison, WI 53714 000-000-0000 • xxxxx.xxx.lac@xxxxx.xxx • xxx.xxxxx-xxxxxxxxxxx.xxx Consent Form for Acupuncture Treatment I, hereby authorize Xxxxx Xxxxxxxx LAc (the Acupuncturist) to perform procedures as necessary to facilitate diagnosis and treatment. Treatment may include: • Acupuncture: insertion of special sterilized needles through the skin into underlying tissues at specific points on the surface of the body. • Cupping: a technique to relieve symptoms in which cups made of glass or other materials are placed on the skin with a vacuum created by heat or other device. • Dermal friction (Gua Sha): rubbing on an area of the body with a blunt, round instrument. • Dietary advice: based on traditional Chinese medical theory. • Electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians. • Infrared therapy: radiant heating using electricity. • Moxa/moxibustion: direct/indirect burning of herbs/herbal blends on an acupoint/meridian using stick, string, Tiger warmer, cone, or ball moxa. • Shiatsu/Tuina: Japanese and Chinese massage used to treat a wide variety of common disharmonies. Risks of Treatment: Acupuncture has been shown to be very safe. However, there are some uncommon but potential risks. These potential risks may include but are not limited to: ▪ Discomfort during and after the insertion of a needle ▪ “Needle sickness” (dizziness, fainting, nausea) ▪ Localized bruising or swelling from needles or cupping ▪ Xxxxx or blisters with the use of moxa ▪ Possible, temporary aggravation of symptoms that existed prior to treatment ▪ Broken needle ▪ Possible organ puncture leading to Infection (very rare) Special Situations: You must inform Xxxxx Xxxxxxxx, X.Xx. if you have severe bleeding disorders, are prone to seizures, wearing a pacemaker or other electronic medical device. All female patients must notify the Acupuncturist or one the staff if they are or believe they may be pregnant. CONSENT TO TREAT I consent to the performance of acupuncture and other procedures for purposes of diagnosis and treatment. I understand that I am free to withdraw my consent and that I may stop treatment or any procedure at any time. I understand that my signature on this form indicates that I have read and understand the preceding information regarding my treatment, including potential risks and benefits as described above. I understand that if I have any questions about this information, I will ask Xxxxx Xxxxxxxx, X.Xx. Signature of Patient Date Signature of Patient’s Representative or Legal Guardian Date

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE Name: Date: ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE AAC-FED A2004 ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)) ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this the Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE (or Patient Representative) X (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO PLEASE SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE ALSO ARBITRATION AGREEMENT AND INFORMED CONSENT TO TREAT CONSENT, PAGE 2 OF 2 – PLEASE SIGN BOTH SIDES I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated named below and/or other licensed licensed/certified acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, bleeding, Gua- Sha, electrical stimulation, Tui-Na (Chinese Oriental massage), Chinese Oriental 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 or in writing. The herbs may have an unpleasant smell or and/or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 cuppingcupping and Gua-Sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses disposable sterile disposable needles and maintains a clean and safe environment. Xxxxx and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: PATIENT SIGNATURE (or Patient Representative) X (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. : . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING SIGING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY JURT OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACTCONTACT. (Date) PATIENT SIGNATURE X Patient Signature: (Or Patient Representative) (Indicate relationship if signing for patient) (Office Signature: Date) OFFICE SIGNATURE X . : Date: ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE PAGE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named names below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinicThe Minneapolis Club, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical Minneapolis Club staff of any unanticipated or unpleasant effects associated with the consumption consumptions of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic Minneapolis Club uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of and treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become becoming pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical acupuncture staff of The Minneapolis Club to exercise my best judgment during the course of treatment which the clinical acupuncture staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical Minneapolis Club acupuncture and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAMEAcupuncturist Name: (Date) PATIENT SIGNATURE X : Patient Signature: (Or Patient Representative) (Indicate relationship if signing for patient)Date: ALSO SIGN THE ARBITRATION AGREEMENT

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAMEALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE NOTICE OF PRIVACY PRACTICES This Notice of Privacy Practices Regarding Disclosure of Health Information describes how health information about you may be used and disclosed. It also describes how you can gain access to your health information. Please review this information carefully. Understanding Your Health Record: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing A record is made each time you visit our office for patient)treatment. This record includes symptoms, clinical observations, diagnosis, and treatment. The record may also contain other pertinent information provided by you or another of your health care practitioners with whom we may have communicated.

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), ) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient) (Date) OFFICE SIGNATURE X . ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese 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. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Xxxxx 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 spontaneous miscarriage, 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. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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. ACUPUNCTURIST NAME: (Date) PATIENT SIGNATURE X (Or Patient Representative) (Indicate relationship if signing for patient)