Dr. Carla M. Edwards, M.S., Ph.D., L.Ac.

1818 Dempster St.

Evanston, IL  60202

 

essencehealingtcm@gmail.com

www.essence-llc.com

 

Informed Consent and Office Policies

 

Dr. Carla Edwards completed her education in the study of Traditional Chinese Medicine (TCM) at Pacific College of Oriental Medicine, is nationally board certified by NCCAOM to practice acupuncture and herbal medicine.  Dr Edwards fulfills the requirements necessary in the practice and application of adjunctive therapies and herbal supplements as defined by the NCCAOM and TCM concepts.

 

Dr Edwards is complying with all rules and regulations promulgated by the Illinois and Colorado Department of Public Health and Environment, including those related to the proper cleaning and sterilization of needles used in the practice of acupuncture and sanitation of acupuncture offices.

 

I (the signer or parent of this document) hereby request and consent to the performance of acupuncture and acupressure treatments on me or on behalf of the patient named below.  I understand that results are not guaranteed.  I intend this consent form to cover my entire course of treatment for my present condition and future conditions for which I seek treatment from Dr. Edwards.

 

I understand that while acupuncture is generally a safe method of treatment, certain adverse effects may result from treatment.  These include minor bruising, puffiness or tingling near the needle sites.  I understand that I should not move (unless directed to do so-example Dr. Tan treatments for pain) while the needles are being inserted, retained or removed to minimize the adverse effects due to the mechanical portion of the treatment. 

 

Other side effects may include the Òhealing crisisÓ category of side effects like post-treatment headaches. I understand that these types of side-effects will manifest within 24 hour of treatment if they will occur at.

 

The herbs and nutritional supplements (which are derived from plant, mineral and animal sources) are considered safe in the practice of Chinese Medicine and Holistic Medicine.  I will immediately notify Dr. Edwards if any unanticipated or unpleasant effects occur associated with the taking of supplements.

 

I understand that Dr. Edwards is providing holistic and TCM care and not providing Western Medical care or those provided by a Medical Doctor (M.D.).

 

Office Policies and Fee Schedule:

 

 

Initial consult/evaluation and treatment (new patients or more than 1.5 years since last visit) $ 160.00

 

Office visit and treatment $90.00 (45 min)

 

Pre-paid package of 6 treatments (acupuncture/NAET)  $420.00

Packages must be used within 6 months of purchase.   24 hour cancellation is

required with package treatments.  If cancellation is less than 24 hours from

appointment time, 1 treatment will be deducted from package.

 

 

Herbal Formulas/Supplements $20.00-$40.00 bottle

Office or Phone consultation (20 min) $65.00

Books $12.00-$25.00

 

We accept cash, personal checks ($20.000 return check fee), MC/VISA as payment.

 

I understand that by making an appointment, time was reserved for me.  Cancellations and changes must be made greater than 24 hours in advance or the missed appointment fee of $30.00 will be added to your next bill.  Package sessions will be refunded upon request and the office visit rate of $90.00 treatment.  Patients who habitually cancel and reschedule appointments may be asked to call for available appointments on a same day basis.

 

 

 

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Patient Name                                                                                      Date

 

 

 

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Patient Signature