Informed Consent for Treatment (Mobile In-Home Services) I, the patient, voluntarily consent to receive Traditional Chinese Medicine (TCM) diagnosis and treatment from Fu Yang TCM in the setting of mobile (in-home) services. 1. Self-Pay Only – Online Payment Only · I understand that this clinic does not accept any health insurance plans. All services are self-pay. · Payment is accepted exclusively online via Wix Payments (credit/debit cards) at the time of booking. The clinic does not accept cash, checks, or any other offline payment methods. · No insurance claims will be submitted, and no superbills will be provided. 2. Treatment Description I understand that TCM treatment may include herbal medicine, acupuncture, moxibustion, cupping, gua sha, acupressure, dietary advice, and lifestyle guidance. Treatment will take place at a location of my choosing (my private residence, office, or other mutually agreed-upon location). 3. Special Considerations for Mobile Services · Environment: I promise to provide a clean, safe, well-lit environment with basic emergency access (e.g., a working phone). · Practice Limitations: I acknowledge that some treatments requiring large equipment may not be available due to environmental constraints. · Personal Responsibility: I am responsible for ensuring that children, pets, or visitors in my home do not interfere with the treatment session. 4. Benefits and Risks of Treatment · Potential Benefits: TCM aims to promote health, relieve symptoms, and potentially reduce reliance on medications. · Risks and Side Effects: · Acupuncture: Possible minor bleeding, local bruising, temporary pain, or dizziness. · Cupping/Gua Sha: May result in skin marks or blisters; these are normal and resolve within a few days. · Herbal Medicine: Rare allergic reactions. · Full Disclosure: I must fully disclose my complete health history (including pregnancy, allergies, implanted metal devices, pacemakers, etc.) and current health status during my in-person consultation. 5. Paper Records Only – No Online Storage · I understand that all my health information will be recorded on paper only. No electronic records (computer, cloud, or online database) will be used to store my personal or health information. · My paper records will be retained for 7 years from my last visit, as required by California law, after which they will be securely shredded. · I may request to view or obtain a copy of my paper records by scheduling an in-person appointment. 6. No Online Medical Advice or Discussions · I understand that this clinic does not provide any medical advice, diagnosis, treatment recommendations, or answers to medical questions through the website, email, text message, or any online platform. · I understand that no patient-specific medical information will be discussed online or over the phone. All medical discussions will take place during my in-person appointment. · If I have a medical concern between appointments, I will schedule an in-person visit or contact my primary care physician. 7. Alternatives I understand that alternative TCM or conventional medical treatment options may exist. I have been informed of these alternatives and have had the opportunity to ask questions during my in-person consultation. 8. Right to Refuse and Withdraw Consent · Right to Refuse Treatment: I have the right to refuse any proposed treatment. Refusal will not affect my future right to receive treatment. · Right to Withdraw Consent: I may withdraw my consent at any time during a treatment session, either verbally or in writing. Once withdrawn, treatment will stop immediately. 9. Emergency I understand that if a medical emergency occurs during treatment, the practitioner may take reasonable first-aid measures and call 911. My information may be provided to emergency personnel. 10. Voluntary Consent I have read and understood all of the above terms. I have had the opportunity to ask questions during my in-person consultation. My questions have been answered to my satisfaction. I hereby voluntarily consent to receive treatment from Fu Yang TCM under the conditions described above.