I, being over 18 years of age (or legal representative if patient is a minor), voluntarily consent to be treated with acupuncture, administered by Guo Chinese Medical Center acupuncturists, licensed in the state of California. I understand that acupuncture is performed by the insertion of needles through the skin, or by the application of heat to the body in an attempt to treat bodily dysfunctions or diseases to bodies physiological functions. The procedure has been fully explained to me. I have been made aware that certain adverse side effects may result. These could include, but are not limited to, some local bruising, minor bleeding, fainting, temporary pain or discomfort, and the possible temporary aggravation of symptoms existing prior to acupuncture treatment. I am also aware that although acupuncture is licensed in California and many other states, and has been safely practiced for centuries, the federal government classifies the procedure "experimental". 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. I have carefully read and I understand all of the foregoing and so am fully aware of what I am signing. I hereby authorize and request the payment of services from insurance plans or payers be made on my behalf to Guo Chinese Medical Center. I hereby assign to Guo Chinese Medical Center all payments for treatment services. I understand and agree that I am responsible for paying any amount not covered by insurance plans or payers.