Acupuncture Consent to Treat


Estimated First Visit Cost:$96

Estimated Subsequent Visit Cost: $50

All fees for services provided at Bruce Chiropractic are due at the time of service. Acupuncture is a Self Pay Service and will not be billed to patient’s insurance plans.

If you for any reason have difficulty meeting the financial arrangements, please speak to a staff member for alternate payment arrangements.

By my signature I agree to be held fully responsible for costs related to treatment rendered & collection of fees in accordance with the terms of this office.


I hereby request and consent to Acupuncture and other procedures including various modes of physical therapy and/or tests by this office. I have had an opportunity to discuss with Dr. Gibbons and/or with other clinic personnel the nature and purpose of treatment indicated. I understand that results are not guaranteed and am informed that, as in the practice of medicine, in the practice of acupuncture there are some risks to treatment, including but not limited to bruising, discomfort, pain, bleeding, and discoloration of skin. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of any procedure which the doctor feels at the time is in my best interest.

I have read, or have had read to me, the above consent and have also had an opportunity to ask questions about it. I consent and by signing below I agree to the above terms and procedures. I intend this consent to cover any treatment for my present condition and for any future condition(s) for which I seek treatment by this clinic and/or any employed staff.

Thank you for taking the time to fill out this form.

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Office Hours

Our Regular Schedule

Lancaster (Historic Downtown)


8:00 am-5:00 pm


7:00 am-4:00 pm


8:00 am-5:00 pm


7:00 am-4:00 pm


6:00 am-1:00 pm