MySpace Healing — Ching Po (Eva) Huang, L.Ac.

Consent & Acknowledgements

Medical Advisory & Informed Consent

I understand that acupuncture and Traditional Chinese Medicine are complementary healthcare therapies and are not a substitute for diagnosis or treatment by a licensed physician. I have been advised to consult a physician regarding any medical conditions for which I am seeking treatment.

I voluntarily consent to receive acupuncture and related Traditional Chinese Medicine treatments from Ching Po (Eva) Huang, L.Ac. Treatment methods may include, but are not limited to: acupuncture needle insertion, manual therapy / therapeutic bodywork, cupping, gua sha, moxibustion, ear seeds, electrical stimulation, infrared heat therapy, herbal consultation and lifestyle recommendations.

I understand that acupuncture is generally considered safe when performed by a licensed practitioner; however, possible side effects may include temporary soreness, bruising, dizziness, fatigue, or fainting. I acknowledge that individual responses to treatment vary and specific outcomes cannot be guaranteed.

I have had the opportunity to ask questions and voluntarily consent to treatment.

Health Information Disclosure

I confirm that the health information I have provided in this intake form is accurate and complete to the best of my knowledge. I agree to inform the practitioner of any changes in my health condition, medications, pregnancy status, or medical diagnoses that may affect treatment.

Privacy & Confidentiality

I understand that my personal health information will be kept confidential and used only for treatment, scheduling, and necessary healthcare administrative purposes in accordance with applicable privacy and confidentiality regulations.

Electronic Communication Consent

I authorize MySpace Healing / Eva Huang, L.Ac. to communicate with me regarding scheduling, intake forms, treatment coordination, and general administrative matters via electronic communication, including email and/or text message.

I understand that electronic communications may not be completely secure and that there is a small risk of unauthorized access. By providing my contact information and selecting my preferences below, I consent to these communications.

I understand that sensitive medical discussions may require phone or in-person communication when appropriate.

Appointment & Cancellation Policy

I understand that appointments require at least 24 hours notice for cancellation or rescheduling. Late cancellations or missed appointments may result in fees according to the policies stated on the MySpace Healing website.

Guardian Consent

The patient is under 18 — a parent or legal guardian must complete this section.