New Patient Intake Form

Dear New Patient,

Welcome to Affinity Acupuncture & Rolfing. We are honored and delighted that you have chosen us as your healthcare providers. We strive to provide a blend of proven ancient Chinese Medicine practices with cutting edge modern advancements, and are committed to your treatment being successful. We look forward to partnering with you to address your health concerns, and we will do all we can to ensure you achieve the most successful result possible for you.

The doctor-patient relationship requires both cooperation and mutual trust. We will strive to provide you with the best possible medical care, and ask that you participate in this effort to the best of your ability.

This welcome letter was prepared to acquaint you with the clinic policies of Affinity Acupuncture & Rolfing. Please review our FAQ under resources on our website if you are a new to acupuncture.

• Wear loose fitting clothes that can be easily rolled up above your elbows and knees. Also, you may need to expose your abdomen from your rib cage to the top of your hips, so please avoid one -piece suits or dresses.
• Be sure you have eaten at least a light meal within a few hours prior to arriving.
• Avoid alcohol on the day of your treatment.
• Drink plenty of water and stay hydrated after your appointment
• For best results, avoid strenuous activity immediately following a treatment. Set aside enough time so that you are not rushing to and from your visit.
• As we follow through on your treatment plan, look for signs of improvement and take encouragement from them. Your belief and expectation has a strong influence on your body, and - is a key factor in healing.

Affinity Acupuncture & Rolfing practitioners act as a team. Each provider is individually responsible for their own treatment style although we strive to communicate together regarding your care and treatment plan. As a team, we share health information.

Fragrance Free Zone: Many of our patients are sensitive to smells. Please avoid wearing any perfume, cologne, or scented lotions to your appointment.

Cell phones and Electronics: Out of consideration for others, please completely turn off your mobile devices or put them in silent mode.

Music/Sound: There is typically music played during treatment. Please speak softly to not disturb other patients resting.

Always report any problems you have with herbs, nutritional supplements or any treatment. Different people react differently to the same treatment or herbal prescription. It is possible for us to properly manage your care only if you tell us about difficulties you are having, or if formulations are not effective or causing you discomfort.

Herbal Formulas/Supplement Price Policy. We may recommend a product to achieve the best outcome for your health and medical needs. We have stock so that you may begin your treatment promptly. We practice fair pricing and will refund the difference, if you find a better priced, retail store product. This does not include online products, but we monitor amazon prices and ours are better.

Payments: Payment is due at time of service. We take cash, check, Venmo and medical credit cards. For Rolfing, we only accept cash or zelle unless otherwise arranged.

Cancellation/Late Policy: If you cancel with less than 24 hours notice, or if you miss a booked appointment, you will be charged $95, the full cost of treatment. If you are more than 15 minutes late to an appointment, we may need to reschedule your appointment.

Non-Refundable Payment Policy: All services and herbs purchased are non-refundable. No refunds will be provided for the full or partial price for any used products or services

Refund Policy on Pre-Paid Packages: Refunds are accepted for “discount prepayment packages” within the first 30 days only. When refunded you will be charged at full rate for each treatment you have used and be refunded the remainder.

Insurance: We participate in many insurance networks and as a courtesy will verify your benefits. Please understand that ultimately, you are responsible for payment should there be any discrepancies with your insurance company at a later date.

Parking: There is NO ON-PREMISE parking. There is plenty of street parking, free and metered taking quarters and credit cards.

Thank you once again for selecting Affinity Acupuncture & Rolfing for your care. Should you have any specific questions that have not been answered, please do not hesitate to ask.

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 Dr. Connie L. Christie, DAOM, L.Ac. 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 Dr. Connie L. Christie, DAOM, L.Ac., including those working at Affinity Acupuncture and Rolfing 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, Tiu-Na (Chinese massage), muscle testing, 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 or 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 site that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual (rare) 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, single use, disposal needles and maintains a clean and safe environment. Burns and/or scarring are a rare potential risk of moxibustion and cupping. I understand that 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 source) that have been recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in larger doses which will not be prescribed. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify Dr. Christie or a clinical staff member who is caring for me if I am pregnant or become pregnant.

I do not expect Dr. Christie or the clinical staff to be able to anticipate all possible risks and complications of treatment, and I wish to rely on Dr. Christie and/or the clinical staff to exercise judgment during the course of treatment which she/them thinks at the time, based upon the facts known, is in my best interest. I understand that results are not guaranteed.

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. I have stated all medical conditions that I am aware of and will update my practitioner of changes in my health status.

Affinity Acupuncture and Rolfing Providers: Dr. Connie L. Christie, DAOM, LAc & Associates

We understand that you may need to cancel or change your appointment. In order to maintain quality patient-centered care, we require a 24-hour cancellation notice when you are unable to keep your scheduled appointment; otherwise you will be charged $95, full price of a standard treatment For rolfing, the first time fee is $200 (full price). Please note, insurance and third party coverage do not pay this fee.

I have read and understand the above policy.

No clients will be treated in the clinic with any viral symptoms such as a fever, cough, or shortness of breath.

I have read and understand the above policy.