Welcome to Well Within Natural Medicine, your resource for Integrative Energy Medicine. Here you will discover a unique blend of healing techniques that are fused together for your own personal healing experience. Our services focus on your body’s energy systems. This document is intended to explain and clarify, to ensure that you understand the nature of the services provided before deciding whether to enter into a professional relationship. Please let us know if you have any questions or concerns as you read and sign this statement.

I hereby request and consent to the use of Traditional Chinese Medicine techniques, including acupuncture, energy medicine, energy psychology, and other associated modalities (nutritional supplementation, homeopathy, flower essences, herbal therapy, moxibustion, heat lamp, GuaSha, cupping, auricular, Tui Na, ESTIM) within the scope of practice of Oriental Medicine and massage therapy by Licensed Acupuncture Physician, Licensed Massage Therapist, and Eden Energy Medicine Advanced Practitioner Melanie A. Smith, of Well Within Natural Medicine, Inc. I understand that I have the right to refuse any or all treatments recommended to me by Well Within Natural Medicine, Inc., And in turn, they have the right to refer me out for treatment or refuse me for treatment. I understand that all the information included in this document pertains to both In-Office and Telehealth Sessions. I also acknowledge that some services such as Acupuncture cannot be conducted via Telehealth and are only available In-Office. Well Within Natural Medicine does not accept personal injury cases.

I am aware that the practice of oriental, alternative, and energy medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatment, diagnostic procedures, or examination.

Energy Medicine: Predating Western medicine, “energy medicine” was being used in various cultures to enhance a person’s physical, mental, and spiritual wellbeing. The National Institutes of Health recognizes energy medicine as one of five basic categories of “Complementary & Alternative Medicine”. Eden Energy Medicine is used to assess disturbances in the body’s energies and helps facilitate a balanced and harmonious energy state. I will use muscle response testing or “energy testing” (adapted and modified from the field of applied kinesiology) to assess the flow of energy in your body and facilitate corrections designed to bring disturbed energies back to a balanced and harmonious state. While these methods are gentle and non-invasive, it is possible that physical and emotional aftereffects may occur when your energies have been stimulated and adjusted. Energy Medicine is compatible with any treatment or procedure prescribed by your physician and is used only as a complement to the standard care that you receive. If at any time you feel uncomfortable with this form of therapy, you have the right to end the treatment. Our work together will be greatly enhanced by your willingness to do energy exercises at home on a daily basis to help balance your own energies.

The herbs, remedies, and nutritional supplements that have been recommended are considered safe in the practice of Oriental Medicine. I understand that they are to be consumed according to the instructions provided both orally and in writing and that some formulations may have an unpleasant taste or smell. I also agree to immediately notify Well Within Natural Medicine, Inc. of any unanticipated or unpleasant effects associated with the consumption of any supplements, remedies, or herbs. I also understand it is my responsibility to disclose to Well Within Natural Medicine, Inc. any and all current medications or natural supplements I am currently taking and if I am or become pregnant or if I feel any side effects during the course of my treatment. Possible side effects may include nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, or tingling of the tongue.

I have been informed that acupuncture is generally a safe method of treatment. Occasionally there may be side effects including bruising, numbness, or tingling near the needling sites and rarely one may experience dizziness or fainting. Bruising is a common side effect of Gua Sha and cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture. Well Within Natural Medicine, Inc. uses sterile, disposable needles and maintains a clean and safe environment to reduce the possibility of infection or contamination. Burns and/or scarring are a potential risk of the heat lamp, moxibustion, and cupping. In case of an accidental needle puncture to myself or another person, I agree to immediately obtain a blood test to test for various diseases including the possibility of Hepatitis, HIV, and AIDS. I further agree to provide a copy of all test results to Well Within Natural Medicine.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I’m also aware that most of these side effects have never resulted from treatment at this clinic or by Melanie A. Smith, AP. I do not expect Well Within Natural Medicine, Inc. to anticipate and explain all possible risks and complications of treatment. I wish to rely on the Acupuncture Physician to keep my best interest in mind and exercise judgment during the course of treatment based on the facts at hand. I understand that results are not guaranteed but do improve with the number of treatments administered. I understand that a minimum of five treatments is recommended. I further acknowledge that the services of the Acupuncture Physician do not replace the treatment of a Primary Care Physician or other medical professionals. I also acknowledge that Well Within Natural Medicine, Inc. is not an emergency treatment facility and that Melanie A. Smith, AP, does not offer emergency treatments. If I require emergency medical treatment or seek treatment outside of posted business hours, I will seek the services of a medical professional, go to an area hospital emergency room, or dial 911.

I understand the staff of Well Within Natural Medicine, Inc. may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent. Except in case of a subpoena or otherwise legally obligated or reasonably allowed to do so (including circumstances where there is clear and imminent danger to yourself or another person). If I am working with other members of your family or legal guardian, we will discuss in advance the kinds of information that I may and may not reveal.

Telehealth Sessions which are also referred to as Energy Medicine Sessions are conducted electronically. While every attempt is made to maintain confidentiality, Well Within Natural Medicine, Inc. cannot be responsible for potential electronic breaches of information.

Well Within Natural Medicine, Inc. maintains a quiet, peaceful, non-smoking, professional office environment for its patients. I agree to respect this policy and to turn off my cell phone and refrain from wearing heavy perfumes during my office visits.

By signing below, I show that I have read or have had read to me the above consent to treatment. I have been told about the potential risks, side effects, and benefits of acupuncture and other procedures and I have had ample opportunity to ask my questions. I understand the nature of the procedures, alternatives, risks, and probable outcomes. I intend this consent form to cover the entire course of treatment for the present and future conditions for which I seek treatment. I agree that I am ultimately personally responsible for my own health care. I knowingly, voluntarily, and intelligently consent to use the services offered by Well Within Natural Medicine, Inc.

I agree to release and indemnify Well Within Natural Medicine, Inc., Melanie A. Smith, AP, and her agents from and against any and all claims for which I (or my representative) may have for any loss, damage, or injury arising out of or in connection with my use of her services. This form is the sole and complete description of the professional relationship, is interpreted under Florida law and Florida will be the forum for any claims filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.

THIS FORM HAS BEEN FULLY EXPLAINED TO ME AND I ACKNOWLEDGE THAT I UNDERSTAND ITS CONTENTS.

I hereby request and consent to the use of Traditional Chinese Medicine techniques, including acupuncture, energy medicine, energy psychology, and other associated modalities (nutritional supplementation, homeopathy, flower essences, herbal therapy, moxibustion, heat lamp, GuaSha, cupping, auricular, Tui Na, ESTIM) within the scope of practice of Oriental Medicine and massage therapy by Licensed Acupuncture Physician, Licensed Massage Therapist, and Eden Energy Medicine Advanced Practitioner Melanie A. Smith, of Well Within Natural Medicine, Inc. I understand that I have the right to refuse any or all treatments recommended to me by Well Within Natural Medicine, Inc., And in turn, they have the right to refer me out for treatment or refuse me for treatment.

I am aware that the practice of oriental alternative and energy medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatment, diagnostic procedures, or examination.

By signing below, I show that I have read or have had read to me the above consent to treatment. I have been told about the potential risks, side effects, and benefits of acupuncture and other procedures and I have had ample opportunity to ask my questions. I understand the nature of the procedures, alternatives, risks, and probable outcomes. I intend this consent form to cover the entire course of treatment for the present and future conditions for which I seek treatment. I agree that I am ultimately personally responsible for my own health care. I knowingly, voluntarily, and intelligently consent to use the services offered by Well Within Natural Medicine, Inc.

I agree to release and indemnify Well Within Natural Medicine, Inc., Melanie A. Smith, AP, and her agents from and against any and all claims for which I (or my representative) may have for any loss, damage, or injury arising out of or in connection with my use of her services. This form is the sole and complete description of the professional relationship, is interpreted under Florida law and Florida will be the forum for any claims filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
THIS FORM HAS BEEN FULLY EXPLAINED TO ME AND I ACKNOWLEDGE THAT I UNDERSTAND ITS CONTENTS.