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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:___________

Attention Veterans:

This Practice Is Now Registered with the Veterans Choice Program under Health Net

The Senate approved a bill the President signed into law authorizing $5.2 billion to extend the current Veterans Choice Program for one year while the VA enacts reforms to expand private care options. Here is a Link to the description of the VA Mission Act 

 

Cancellation Policy

At least 24 Hours in advance.