CONSENT: I hereby request and consent to treatment by Citylife Wellness Acupuncture P.C. and by the acupuncturist named above and/or other licensed acupuncturists who now, or in the future, treat me while employed by, working or associated with, or serving as back-up for, the acupuncturist named above, including those working at the clinic or office listed above or any other office or clinic, whether signatories to this form or not. I understand that acupuncture is not a surgical procedure and is not intended as a substitute for cosmetic surgery.

Type of care

I have had an opportunity to discuss with the acupuncturist the nature and purpose of the acupuncture and treatment to which I consent. I understand that acupuncture treatment involves the insertion of acupuncture needles into the face, neck, and body and that, according to the theory of Traditional Chinese Medicine (TCM), the insertion of these needles is designed to facilitate the flow of Qi (energy) along meridians or pathways throughout the entire body. I understand my treatment plan may be modified to address (1) changes in my condition, (2) changes in my desired results, or (3) changes in the professional standards of acupuncture care. I understand and agree to adjustments in my treatment as needed to optimally address my well-being and objectives and take advantage of my full range of care options.

Potential benefits

I understand that acupuncture treatment aims to create a younger and more vibrant appearance by properly balancing the flow of Qi. This may include enhanced skin tone, improved luster of complexion, decreased puffiness around the eyes, elimination or reduction of fine wrinkles, improved muscle tone, a firming of sagging skin, and a lessening of the visible signs of aging. However, as with all TCM care, acupuncture treatment involves a gradual, healthful process customized for each patient, and individual results may vary.

No guarantee

I understand that results are not guaranteed. My questions regarding the longevity of results and potential changes in my facial appearance have been answered. Although good results are expected, there is no guarantee or warranty of the results that may be obtained, either expressed or implied.

Risks of acupuncture and TCM care

I understand that every procedure involves a certain amount of risk, including acupuncture and treatment. Some of the more common complications are listed below. I understand and am informed that even though the majority of patients do not experience these complications, problems may arise for me:

• Bleeding and bruising — When a needle is removed, some minor bleeding may occur. This is normal and usually will not leave a bruise. Occasionally, a bruise or hematoma may appear. With bruising, you must wear sunscreen when going outside. Topical and internal remedies will be discussed to address bruising. If swelling persists, I should call my provider immediately.
• Infection — Infection at the needle site is rare because the needles are sterile. If I suspect infection (for example redness, swelling, or warmth to the touch), I will call my provider immediately. Additional treatment or a referral to my M.D. may be necessary.
• Damage to deeper structures — Deeper structures such as blood vessels, nerves, and muscles are rarely damaged during a cosmetic acupuncture treatment. If this does occur, the injury may be temporary or permanent.
• Asymmetry — All facial structures are naturally asymmetrical. Results may vary from side to side due to natural asymmetry, previous injuries, or the severity of symptoms on one side or the other.
• Nerve injury — Injury to the motor or sensory nerve very rarely results from facial acupuncture treatments. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Injury to the sensory nerves of the face, neck, and ear regions may cause temporary or, more rarely, permanent numbness. Painful nerve scarring is extremely rare.
• Needle shock — Needle shock is a rare complication that can happen during any acupuncture treatment. I should notify my provider immediately if I feel faint or shaky during the treatment.
• Allergic reaction — Rare cases of local allergies to topical preparations or serious systemic reactions to herbs used during acupuncture can occur. Skin testing may be done before applying herbal preparations.
• Delayed healing — Delayed healing is rare but can be influenced by smoking or certain health conditions such as diabetes and chronic fatigue syndrome.
• Unsatisfactory results — I acknowledge I am not having a surgical procedure and understand the alternatives, risks, and healing responses described in this consent.
• Long-term effects — Changes in facial appearance also occur due to aging, sun exposure, stress, and other factors unrelated to acupuncture. Non-compliance with lifestyle or dietary instructions may adversely affect the longevity of results.
• Unforeseeable impacts — Many variable conditions exist, and future treatments may be necessary to maintain results.

Alternative treatment

I acknowledge that other alternatives for cosmetic care exist, such as surgical facelifts, chemical peels, or liposuction, and that those alternatives carry their own risks.

Health insurance / financial responsibility

I understand that most health insurance does not cover the cost of cosmetic acupuncture treatments or complications arising from them. I agree to be responsible for charges not covered by insurance.

Unforeseen conditions

I acknowledge that there are various styles of treatment (TCM care, facial, cosmetic, and rejuvenation acupuncture) and that unforeseen conditions during treatment may necessitate procedures different from those initially contemplated.

Agreement and continuous effect

I have read, or have had read to me, this informed consent. I understand the risks and alternatives, have had my questions answered, and am satisfied with the information provided. I authorize the release of medical information as needed for my care. This consent covers the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment at this clinic.

I hereby consent to receive facial treatment at Citylife Wellness Acupuncture P.C.. I acknowledge that the purpose of this facial is primarily to relax and cleanse the skin.

I understand that while the facial treatment is performed by skilled practitioners, any discomfort or pain experienced during the session should be promptly communicated to the practitioner so adjustments can be made to ensure my comfort and safety throughout the procedure. Furthermore, I recognize that facials are not intended to replace medical examinations, diagnoses, or treatments. Should I have any medical concerns or conditions, I agree to seek advice from a qualified physician.

By signing this consent form, I affirm that I have disclosed all relevant medical information truthfully and accurately. I understand the importance of informing the practitioner and Citylife Wellness Acupuncture P.C. of any changes to my medical history, and I accept that failure to do so may affect the outcome of the treatment, for which neither the practitioner nor the Center shall be held liable.

I acknowledge that any inappropriate or sexually suggestive behavior on my part will result in the immediate termination of the session. In such cases, I understand that I will be responsible for payment of the scheduled appointment and may be subject to legal action. In addition, I understand that the facial treatment may involve using various products, tools, and techniques tailored to my skin needs. These may include but are not limited to cleansers, exfoliants, masks, steam, extractions, and moisturizers. I acknowledge that while the practitioners at Citylife Wellness Acupuncture P.C. are highly trained professionals, risks may be associated with certain ingredients or procedures, such as allergic reactions or skin sensitivity. I agree to disclose any known allergies or sensitivities to the practitioner before the commencement of the treatment.

Moreover, I recognize that the facial treatment results may vary depending on factors such as my skin type, lifestyle, and adherence to post-treatment care recommendations. I acknowledge that the practitioner may provide guidance on maintaining the facial benefits at home, including proper skincare routines and product recommendations. I agree to follow these instructions to optimize the outcome of the treatment and extend its benefits beyond the Center environment.

By signing below, I affirm that I have read and understood all the information provided in this consent form, and I voluntarily consent to undergo the facial treatment described herein. I acknowledge that I have had sufficient opportunity to ask questions and seek clarification on any aspect of the treatment before providing my consent.

I know the potential risks, benefits, and alternatives of physical therapy treatment. The therapist provides a wide range of services, and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition.

Potential benefits

I may experience an improvement in my symptoms and an increase in my ability to perform my daily activities. I may experience increased strength, awareness, flexibility, and endurance in my movements. I may experience decreased pain and discomfort. I should learn more about managing my condition and the resources available.

Potential risks

I understand I may experience an increase in my current level of pain or discomfort or an aggravation of my existing injury. This discomfort is usually temporary; I agree to contact my physical therapist if it does not subside in 24 hours.

No warranty

I understand that my physical therapist cannot make any promises or guarantees regarding a cure for or improvement in my condition. I understand that my physical therapist will share with me his or her opinions regarding the potential results of physical therapy treatment for my condition and will discuss treatment options with me before I consent to treatment.

Alternatives

If I do not wish to participate in the therapy program, I will discuss my medical, surgical, or pharmacological alternatives with my physician or primary care provider.

I hereby authorize Citylife Wellness Acupuncture P.C., consultants, contractors and sub-contractors, and other healthcare professionals providing services on behalf of Citylife Wellness Acupuncture P.C. to provide care and administer treatment and procedures as deemed necessary or advisable to me or the named patient each time I or the named patient present for care. I have been informed of risks and complications that may occur and alternatives that may be available. I acknowledge that no guarantees or assurances have been made concerning the results intended for the treatment. And I confirm that I have read and fully understand the above.

K Wellness implements administrative, physical, and technical safeguards to protect your Protected Health Information (PHI) under the HIPAA Privacy and Security Rules. PHI may be used and disclosed for treatment, payment, and health care operations as permitted by law.

We apply the minimum necessary standard when sharing PHI. You may request access to your records, an amendment, a restriction on certain disclosures, an accounting of certain disclosures, or file a privacy complaint. Use the Privacy tab in Personal Information or contact the clinic Privacy Officer.

Workforce training and vendor Business Associate Agreements are maintained under clinic policy. AI-assisted documentation is reviewed by licensed providers before it becomes part of your medical record. Results and experiences vary; this notice is not a certification seal.

By acknowledging, you confirm you have had an opportunity to review this Notice of Privacy Practices.

AUTHORIZATION: I authorize Citylife Wellness Acupuncture P.C. (doing business as K Wellness / K Wellness NYC), its licensed practitioners, staff, and authorized agents to take photographs and/or digital images of my face, body treatment areas, and related clinical findings in connection with my care at the studio (38 W 32nd St, Suite 604, New York, NY) and services offered through kwellnessnyc.com.

Permitted uses

1. Clinical / internal examination — To document my condition before, during, and after treatment; to support examination, treatment planning, progress review, quality assurance, and internal staff training under HIPAA-compliant clinic policies.
2. Before-and-after documentation — To create before-and-after records of my treatment results for clinical comparison and, when used publicly, for educational or marketing display on kwellnessnyc.com and on K Wellness official social media or advertising channels that promote the clinic website.
3. Dispute / complaint documentation — If a disagreement, complaint, chargeback, insurance dispute, claim, or other dispute arises regarding treatment results, appearance outcomes, billing, or quality of care, I authorize K Wellness to use these photographs as contemporaneous clinical evidence documenting the care provided and my presentation before and after treatment.

Identifiability

I understand that photographs of my face or other distinctive features may identify me. For website or marketing use, K Wellness will make reasonable efforts to present images in a professional clinical manner; however, full anonymity cannot be guaranteed for facial photographs.

Storage and privacy

Images retained in my clinical record are Protected Health Information (PHI) and are safeguarded under the HIPAA Privacy and Security Rules and our Notice of Privacy Practices. Website and marketing uses are made under this written authorization. I understand that once an image is published online, third parties may copy or reshare it beyond the clinic’s control.

Refusal or withdrawal of marketing use

I may refuse or later withdraw authorization for public / marketing use of my photographs by notifying the clinic in writing (including email to ****@*******.com). Refusal or withdrawal of marketing authorization will not affect my right to receive medically appropriate care. Withdrawal does not require K Wellness to remove images already published, images retained in my medical record as permitted by law, or images already used in a pending dispute or legal matter. Clinical-record photographs may still be retained as part of my chart.

Agreement

By checking the photography consent box and signing this intake, I confirm that I have read this authorization, understand it, and voluntarily agree to the photography uses described above for my present course of care at K Wellness and for future visits, unless I revoke marketing authorization in writing as described above.