Page 7 – Disclaimer (Sign here) ---
DISCLAIMER
1. No emergency services: This practice does not provide emergency or urgent care. If
you have severe pain, difficulty breathing, severe allergic reaction, unusual bleeding, or
any life-threatening condition, call 911 or go to the nearest ER immediately. Do
not wait for a follow-up visit.

2. Not a substitute for primary care: TCM therapies do not replace the advice of your
medical doctor. Continue following your physician’s orders, especially regarding
prescription medications.

3. Individual results vary: No specific outcome is guaranteed. Results depend on many
factors including individual constitution and compliance.

4. Practitioner-patient relationship: A formal practitioner-patient relationship is
established only when you sign this entire consent package AND the practitioner begins
providing services. Website inquiries, emails, or appointment requests do not create a
relationship.

5. Scope of practice: The practitioner is a licensed Acupuncturist (L.Ac.) in California.
Services are provided within the scope defined by California Business and Professions
Code section 4937 (promoting, maintaining, or restoring health). For non-insurance
patients, this includes whole-body balance approaches consistent with classical TCM.

I have read and understand this Disclaimer.

Patient signature: ____________________
Date: _______________________