Schedule

Call or Text

Karli Azevedo, EAMP • 509.885.8329
Jaymie Bolander, LMT • 509.885.8328
Nanci Corder, EAMP • 509.393.1166

Please be sure to contact all three providers in case one of us is out of the office, ect. that way you will be sure to connect with at least one of us and we will be able to help you.

Email

health@core-essence.org

Insurance

We do not bill insurance on behalf of the patient, but we can provide you with a super bill that you may submit to your insurance company with a claim form downloaded from their website, and they will reimburse you directly depending on your specific policy plan.

Payment

Please be prepared to pay in full at the beginning of your appointment via:

Cash {preferred}
Check {made payable to Core Essence}
Card {debit, credit, health savings account} …there is an additional $5 charge for card processing fees

Patient Forms

You may fill out the below paperwork prior to your appointment or please come early to do so.

Health History Questionnaire

Community Acupuncture

Informed Consent For Acupuncture Treatment

Treatment

Your treatment may include the following techniques. Feel free to ask your practitioner questions regarding treatment techniques. • Acupuncture—The insertion of special sterilized, disposable needles through the skin into the underlying tissues at specific points on the surface of the body. • Moxibustion (Moxa)—The burning of prepared herbs on or near the body to warm, strengthen and relieve symptoms. Moxa comes in several forms such as stick, string, ball, cone or rice grain. • Cupping—A technique used to relieve symptoms by applying cups made of glass or plastic to the skin with a vacuum created by heat or suction. • Electro Acupuncture—The use of very low electrical current applied to specific acupuncture points. • Acupressure—A technique of Chinese medical pressure based on acupuncture theory, used for a variety of common disorders. • Gua Sha—Rubbing on an area of the body with a blunt, round instrument that releases toxins and moves stagnation. • Plum Blossom or Seven Star Hammer—A light tapping of an area of the body with a small sterile, disposable hammer which has seven points. • Dietary Advice—Food and herbal advice guided by traditional Chinese theory. • Infrared Lamp—The use of heat to warm the body and increase circulation to an area. • Press Seeds/Beads/Magnets—A self-adhesive seed, bead or magnet is applied to specific acupuncture points on the body or ears for stimulation.

Purpose of Treatment

The purpose of your treatment is to resolve your complaint, i.e., the reason you are seeking treatment. Acupuncture is a comprehensive health care system that is based on East Asian medicine theory and practices. Diagnosis and treatment based on these theories and practices are used to promote your health and treat both organic and/or functional disorders.

Potential Benefits

Potential benefits from the above procedures can lead to relief of presenting symptoms, and the rebalancing of internal systems so as to lead to the elimination and/or prevention of the main complaint, reduction of stress, and an awareness of dietary and life-style changes in order to maximize health and well-being. Many conditions may be alleviated very rapidly; others, especially those, which have developed and/or existed over the course of many years, may be relieved only through a slow and steady treatment protocol.

Risks of Treatment

Acupuncture has been shown to be relatively safe. However, there are some uncommon but potential risks, including • Needle “sickness” (dizziness, fainting, nausea after insertion of needles) • Localized, minor bruising or swelling • Minor burns with the use of moxa • Possible aggravation of symptoms that existed prior to treatment • Broken needle (very rare with the use of disposable needles) • Infection (very rare with the use of disposable needles)

Some acupuncture points are contra-indicated during pregnancy. Please inform your practitioner if you are or might be pregnant. In addition, patients with severe bleeding disorders or pacemakers should inform the practitioner prior to treatment.

Use of disposable needles

To reduce the possibility of infection, all needles used by your practitioner are pre-sterilized, one-time-use needles made of surgical stainless steel. After each treatment needles are disposed of as medical waste. Needles are never reused.

Confidentiality of Medical Records

All medical records will be kept confidential as provided by law. Your medical records will not be released to anyone without your written consent. Your privacy will be protected. We are a HIPPA compliant office. There is an optional Photo Release Form to sign if you give consent for photos, videos and/or clinical information regarding you to be used for the purposes of research, education and creating case studies.

Requirement of Washington State Law

Washington State Law does not permit acupuncturists to treat certain disorders without the consultation of a medical doctor, • Cardiac conditions including uncontrolled hypertension • Acute abdominal symptoms • Acute undiagnosed neurological changes • Unexplained weight loss in excess of 15% of body weight within a 3 month period • Suspected bone fracture or dislocation • Suspected systemic infection • Any serious undiagnosed hemorrhagic disorder • Acute respiratory distress without previous history or diagnosis

Treatment Consent

With this knowledge, I voluntarily consent to the above treatment procedures, realizing that no guarantees have been given to me regarding the resolution or improvement of my condition. I understand that I am free to withdraw my consent and that I may stop treatment or any procedure at any time. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgement during the course of treatment, which the clinical staff thinks at the time based upon facts then known, is in my very best interest. Group Exposure: Some confidentiality may be partially lost in group settings such as Community Acupuncture, multiple appointments at the same time in an open-air setting, visibility of patients coming and going, and healthcare information shared and disclosed by other participants. If I have any questions about this information or about my treatment, I will ask my practitioner. I hereby release Core Essence Acupuncture from any and all liability that may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. My signature on this form indicates that I have read and understand the preceding information.

Patient Name

First Name

Last Name

Parent or Gaurdian

(for patients under 18 years of age)

First Name

Last Name

Date

YYYY

I acknowledge that I have read and agree to give consent for acupuncture treatment

Patient Notification Of Qualifications And Scope Of Practice

Appointments