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Meridian Health Seattle

Acupuncture, Massage Therapy & Chinese Herbal Medicine

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Forms

1. Intake Form

INTAKE FORM – Choose below to PRINT OUT the PDF form prior to coming to the office and bring it with you -OR- FILL OUT the form online and have it waiting in the office.

PRINT OUT FORM
FILL-IN ONLINE

2. Notification Policy

NOTIFICATION POLICY – Please make sure to read the “Patient Notification of Qualifications and Scope of Practice” below or CLICK HERE to print out a PDF copy of the notification.  Thank you!

PRINT OUT NOTIFICATION POLICY

Law requires the Department of Health to develop a form for East Asian medicine practitioners to use to inform the public of the practitioners’ scope of practice and qualifications. (18.06.130 RCW) The practitioner must fill out this form and give it to each patient in writing prior to or at the time of the initial patient visit. (246-803-300 WAC)

Patient Notification of Qualifications and Scope of Practice

East Asian medicine means a health care service using East Asian medicine diagnosis and treatment to promote health and treat organic or functional disorders.
  1. My qualifications include the following education and license information:
    • Bastyr University, Masters of Science Degree in Acupuncture 1997
    • Brenneke School of Massage Graduate 1996
    • Bastyr University, Chinese Herbal Medicine Certification 1999
  2. The scope of practice for an East Asian medicine practitioner in the state of Washington includes the following:
    • (a) Acupuncture, including the use of acupuncture needles or lancets to directly or indirectly stimulate acupuncture points and meridians;
    • (b) Use of electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians;
    • (c) Moxibustion;
    • (d) Acupressure;
    • (e) Cupping;
    • (c) Moxibustion;
    • (d) Acupressure;
    • (e) Cupping;
    • (f) Dermal friction technique;
    • (g) Infra-red;
    • (h) Sonopuncture;
    • (i) Laserpuncture;
    • (j) Point injection therapy (aquapuncture); and
    • (k) Dietary advice and health education based on East Asian medical theory, including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements;
    • (l) Breathing, relaxation, and East Asian exercise techniques;
    • (m) Qi gong;
    • (n) East Asian massage and Tui na, which is a method of East Asian bodywork, characterized by the kneading, pressing, rolling, shaking, and stretching of the body and does not include spinal manipulation; and
    • (o) Superficial heat and cold therapies.
  3. Side effects may include, but are not limited to:
    • (a) Pain following treatment;
    • (b) Minor bruising;
    • (c) Infection;
    • (d) Needle sickness; and
    • (e)Broken needle.
  4. The patient must inform the East Asian medicine practitioner if the patient has a severe bleeding disorder or pace maker prior to any treatment.

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