Informed Consent & Cancellation Policy
DECLARATION AND CONSENT TO TREATMENT
Date:_________ Patient Name:___________________________________
This is to acknowledge that I have been informed and I understand that:
Any treatment or advice provided to me as a patient of Sharon Gordon, M.Ac., Dipl.Ac., is not mutually exclusive from any treatment or advice that I may now be receiving or may in the future receive from another health care provider.
I am at liberty to seek or continue medical care from a physician, surgeon or other health care provider. All information I disclose during my consult and course of treatment with Sharon Gordon, M.Ac., Dipl.Ac. remains strictly confidential.
I agree to pay for services at the time of each treatment by either cash or check.
*Superbill arrangements can be made for your records or insurance benefit provider.
Cancellation & Rescheduling Policy:
Give me a quick call, email or text message 24 hours prior to appointment.
Day of cancellation or no-show you will be the full session fee for missing an appointment. Re-scheduling with me within a week waives the fee. Illness or emergencies will also waive the fee.
I have read, accept the terms and hereby do authorize and consent to treatment from Sharon A. Gordon, M.Ac., Dipl.Ac.
Patient Signature_______________________________Date:___________
