Consent to Custom-made TCM Herbal Treatment
Dr. Ching H. Wu LicAc, Dipl. Ac. NCCAOM, MS TCM, PhD Eng
Wu’s Acupuncture and Herbs
I understand the intention of the Wu’s Acupuncture and Herbs is to help me maintain or improve my well being through the prescription of traditional Chinese medicine herbs. I understand that the traditional Chinese medicine herbs may or may not work for me.
I hereby consent and request Dr. Wu of Wu’s Acupuncture and Herbs to administer the traditional Chinese medicine herbal treatment. I am willing to accept the consequences of the custom-made traditional Chinese medicine herbal treatment.
In consideration of the treatment for me, I hereby agree (1) not to commence any litigation against Dr. Ching H. Wu and/or Wu’s Acupuncture and Herbs for any reason associated with the application of the traditional Chinese medicine herbs, (2) to release Dr Ching H. Wu and/or Wu’s Acupuncture and Herbs from any claim whatsoever arising or which may arise from the application of such treatment, and (3) to resolve any complaint through binding arbitration..
I understand that the fees for all services and purchases are to be paid in full and are not refundable.
I have read the above or had them translated to me in my native language; and I fully understand the contents of the above sentences.