Non-Covered Service Waiver - CUPPING

My acupuncturist may recommend that I receive Cupping as an adjunct to my regular treatment. If this is recommended, the procedure will be fully explained to me beforehand, and I will have the opportunity to choose or decline this part of treatment.

I understand that my insurance does not consider Cupping to be a covered benefit and will not pay for my acupuncturist to perform Cupping therapy. I acknowledge that I have been informed in advance of receiving these services, that these services are not covered by my health insurance plan. I also agree that if I choose to receive these services during any treatment session, I will be financially responsible for the charges.

Patient Name(Required)
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