In order for you to receive the most comprehensive care from your health care providers, we would like to provide your primary care physician and any other health care providers you indicate with notes of your benefits and progress from acupuncture treatment. If you would like us to do that, please read the below statement and fill out and sign the form.
I understand that my health information is private and that use of my health information must be consistent with the previously signed Notice of Privacy Practices. I further understand that certain disclosures of my health information may only be provided by my written consent. I therefore make the following request and understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.
authorize Strength & Vitality Wellness to disclose information regarding my health information to:
Relationship Status: SingleMarriedPartneredDivorcedWidowed
Name of Spouse/Partner if applicable
Number of Children
Family History of Serious Illnesses
Cancer Diabetes Stroke Heart Disease
To educate and empower the individuals that make up families to live in optimal
wellness. We have chosen an approach that is comprehensive and in partnership with other
By signing below, I do hereby voluntarily consent to be treated with Acupuncture and/or Whole Food Supplements
by Cara-Michele Nether, M.Ac, L.Ac. I understand that Cara-Michele Nether has earned a Master's Degree from
Tai Sophia Institute for the Healing Arts, a nationally respected institution in the field of acupuncture and herbal
medicine and is completing a training program with the International Foundation for Nutrition and Healing. She has
obtained her license from the Maryland State Board of Acupuncture. I have the right to ask for copies of her license.
I understand that acupuncturists and nutrition counselors practicing in the state of Maryland are not primary care
providers and that regular primary care by a licensed physician is an important choice that is strongly recommended.
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin
or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to
treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions.
I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor
bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment.
I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture
treatment at any time.
Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring
from its use. I understand that I may refuse this therapy.
Nutrition: I understand that Cara-Michele Nether will be recommending supplementation and nutritional programs based upon
her understanding and experience as a Nutritional Consultant. I also understand that nutritional programs are never intended
as medical advice and do not replace the need for medical treatment and/or advice from my physician. I have been advised
to consult with my physician prior to starting the supplementation and nutritional program.
I understand that it is my responsibility as a client to inform my practitioner, Cara-Michele Nether, about all aspects of my
health and, as treatment progresses, to inform her of any changes that occur. If I experience any pain, discomfort, possible
adverse reactions or side effects, it is my responsibility to immediately notify my practitioner.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.
I have carefully read and understand all of the above information and am fully aware of what I am signing.
I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.