Care & Financial Plan

Care Plan

Relief Care (X Week/Month)

for X Weeks/Months

Corrective Care (X Week/Month)

for X Weeks/Months

Maintenance & Wellness Care (X Week/Month)

for X Weeks/Months

Goals

Treatment Plan

Recommendations

Oriental Nutrition
Meridian Exercise
Herbal Therapy
Self-Care Education
Meditation
Other

Additional Notes

Date of Reevaluation

Financial Policy

Care Plan Details

Insurance Coverage

Number of Visits

Co-Pay

# of Acupuncture Visits

@ Price = $

Notes

# of Reevaluation

@ Price = $

Notes

# of Cupping/Gua Sha/Tui Na

@ Price = $

Notes

# of Hot/Cold/Moxa Therapy

@ Price = $

Notes

# of Self-Care Education

@ Price = $

Notes

# of Consulting

@ Price = $

Notes

# of Herbal Therapy

@ Price = $

Notes

Estimated Health Care Investment

Monthly Plan

I, [name]

will pay for all outlined acupuncture treatments and services every [frequency]

weeks on the [date]

and the [date]

of the month for a total of [total months]

months until my obligation is paid in full. The first instalment of my payment is due on [date]

I authorise my practitioner to charge my credit card monthly in the amount of [amount]

Prepayment Plan

I, [name]

would like to pay for my entire treatment plan with a one-time payment of [amount]

Time of Service Plan

I, [name]

would like to pay for each of my treatments and services on the day I receive them.

User Agreement

I understand and agree to my Acupuncture Care Plan and financial obligation.  I also understand that the success of this plan is dependent upon keeping my appointments, following my acupuncturist's instructions and communicating with my acupuncturist about my case, care and treatment.

Patient Signature

Date

Acupuncturist Signature

Date