Joint Informed Consent & Release of Liability

Concurrent Acupuncture & Physical Therapy Treatment — Effective August 2026

By signing this form, I voluntarily consent to receive (a) acupuncture and related therapies provided by Emily Jane Crouch, DOM-AP, and (b) physical therapy evaluation and treatment provided by Dr. Eran Kabakov, PT, as determined appropriate by each practitioner based on my health history and treatment goals. I understand that these are two distinct licensed disciplines delivered by two independent practitioners, who may treat me simultaneously in the same session or in coordination with one another. I release each practitioner and their respective practice from responsibility for issues related or unrelated to my care, except in cases of negligence. In the event of a medical emergency, I understand that I should seek immediate care at a hospital, as neither acupuncture nor physical therapy is practiced as a form of emergency medicine.

For details on how your health information is used and protected, please see the separate Notice of Privacy Practices provided by each practice.

1Nature of Concurrent Treatment

Acupuncture and physical therapy may be provided at the same time, in the same treatment space, by both practitioners working together, or back-to-back within the same visit, as clinically appropriate.

Each practitioner independently evaluates whether concurrent treatment is suitable for me based on my health history and presenting condition.

I may request that the two treatments be scheduled separately, rather than concurrently, at any time.

2Risks, Side Effects, and Patient Guidelines

As with any therapeutic treatment, outcomes cannot be guaranteed. Known risks include:

Acupuncture carries some risk of side effects, including bruising, minor bleeding, fainting, discomfort, or a temporary increase in existing symptoms.

Physical therapy and exercise may involve temporary soreness, discomfort, fatigue, or, in rare cases, injury.

Notify either practitioner promptly if discomfort is experienced during the session.

Follow the recommended course of treatment and any lifestyle, nutritional, or exercise guidance provided by either practitioner.

I agree to inform my provider(s) of any medical condition, symptom, medication, or change in my health that could affect my treatment.

3Medical History Disclosure

I confirm that I have disclosed any relevant medical conditions to both practitioners, including pregnancy, cardiac pacemakers or implanted devices, bleeding disorders, recent surgeries or injuries, or use of blood-thinning medication, as these may affect the safety of either or both treatments.

4Release of Liability

I release Emily Jane Crouch and Ancient Art Acupuncture from claims or liability related to the acupuncture services provided, except in cases of negligence by the practitioner.

I release Dr. Eran Kabakov and Concierge Physical Therapy from claims or liability related to the physical therapy services provided, except in cases of negligence, gross negligence, or intentional misconduct.

I understand that each practitioner is responsible only for their own scope of practice, and neither practitioner nor practice is liable for the acts or omissions of the other.

I understand treatment may involve risk of physical injury, illness, or emotional distress that cannot be fully eliminated, and I accept these risks.

I am responsible for any harm caused by my own actions or negligence during treatment.

5Fees, Payment, and Cancellation Policy

Payment in full is due at the time of service, unless alternative arrangements have been made in writing with the applicable practice. Acupuncture and physical therapy services are billed separately by Ancient Art Acupuncture and Concierge Physical Therapy respectively, unless otherwise agreed in writing.

Appointments cancelled or rescheduled with less than 24 hours' notice, as well as missed appointments, will be charged the full session fee by each affected practice. Fees are subject to change; any changes will be communicated in advance.

6Right to Withdraw Consent and Terminate Care

My consent is voluntary, and I may withdraw it or stop treatment — with either or both practitioners — at any time. This Agreement may also be terminated by any party with written notice; upon termination, any unpaid fees for services already rendered become immediately due and payable.

7Governing Law

This Agreement is governed by the laws of the State of Florida.

Patient Acknowledgment

I have read (or had read to me) this entire form, understand it, and had the opportunity to ask questions. I voluntarily consent to concurrent acupuncture and physical therapy treatment as described above.

Patient Full Name *

Cell Phone Number *

Parent / Guardian Name (if patient is a minor)

Date

August 18, 2026

I have read and understand all sections of this Informed Consent & Release of Liability. By checking this box and submitting my name above, I am providing my digital signature and voluntarily consenting to treatment.

Your submission is encrypted and stored securely. A copy will be saved to your practitioner's records.