Page 3 – Mobile Service Disclosure (Sign here) ---
ADDITIONAL DISCLOSURE FOR MOBILE SERVICES (HOME VISIT
SETTING)
You have chosen to receive TCM services in your home. The practitioner is a licensed
acupuncturist (L.Ac.) in California, providing mobile (house call) services.
You are hereby informed of the following specific risks associated with receiving treatment in a
non-clinic environment:
1. Home environment risks: Unlike a clinical setting, your home may have pets, children,
furniture, or other obstacles that can cause accidental injury. Emergency equipment and
space for emergency response may be limited.
2. No emergency care: The practitioner does not provide emergency medical services. If
you experience severe pain, difficulty breathing, severe allergic reaction, unusual
bleeding, chest pain, loss of consciousness, or any life-threatening condition during or
after the visit, you must call 911 immediately or go to the nearest emergency room. Do
not wait for the practitioner to return.
3. Scope of practice: The practitioner is a licensed acupuncturist, not a medical doctor,
chiropractor, or emergency physician. Treatment is limited to TCM modalities as
described in this consent package. Any need for diagnosis or treatment outside of TCM
will be referred to an appropriate medical provider.
4. Your responsibility for a safe treatment environment: You agrees to provide a
clean, well-lit, and unobstructed area for the treatment. You will keep pets and children
away from the treatment space. You will inform the practitioner of any hazards (e.g.,
slippery floors, unstable furniture, aggressive pets) before treatment begins.
5. Voluntary acceptance of mobile setting risks: After understanding the above risks
of receiving TCM services in your home, you voluntarily choose to proceed with mobile
(house call) treatment.

I have read, understood, and agree to the above additional disclosures for
mobile TCM services.

Patient signature: ____________________
Date: __________________