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Fu Yang TCM

New Patient Legal Consent Package – Final Version (English Only – Mobile TCM)

 

Practitioner Name: ______________________ L.Ac.

License#: ________________________

Phone: _______________________

 

This package contains (9 pages):

 

1.     Cover Page

2.     Informed Consent for TCM Services

3.     Additional Disclosure for Mobile TCM Services (Home Visit)

4.     Cupping Risk Disclosure (Stationary Cups, <10 min)

5.     Classical Herbal Medicine Informed Consent & Voluntary Use Statement

6.     HIPAA Privacy Policy (Paper-based, Offline)

7.     Disclaimer

8.     Master Signature Page

9.     Intake & Follow-up Form (Chinese & English – for each visit)

Instructions for patient:

·        Read and sign pages 2 through 8 on your first visit.

·        Page 9 is used for every visit (initial intake + follow-up SOAP).

·        Practitioner will keep all signed documents for 7 years as
required by California law.

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