KMA Policies and Patient Forms

COVID-19 Pandemic Phase One Reopening Policies and Patient Forms: Upon resuming your acupuncture and massage treatments at KMA during Maryland’s Phase One Reopening period, the Maryland Department of Health requires practitioners and patients to agree to and abide by certain rules and guidelines. Please review the Full COVID-19 Policies and Procedures below prior to resuming your treatments at KMA. Scheduling an appointment with us indicates you understand and agree to our current COVID-19 Policies and Procedures.

Questions about these policies and procedures may be directed to our Office Manager.

Full Covid 19 Policies and Procedures for Patients 5_27_20

All patients will be required to sign the COVID-19 Pandemic Acknowledgement and Informed Consent upon resuming treatment. Please print and initial this form. Per emergency executive orders to decrease contact during the COVID-19 pandemic, you may sign your own Consent form before you arrive at our office. If you are unable to print this form before arriving in our clinic, one will be provided to you.

COVID Pandemic Treatment Consent

Feeling Overwhelmed? Print this Easy Treatment Preparation Checklist for Patients to help you get ready for your appointment.

Easy Patient Preparedness Checklist

New Patient Forms: Please print the Consent to Services and Intake Form prior to your first visit. We encourage you to fill out these forms in detail prior to your arrival so that we may begin your treatment promptly.  Our comprehensive Intake Form is designed to allow us to craft a detailed treatment plan specific to your needs. For your benefit, please complete this form entirely. Per emergency executive orders to decrease contact during the COVID-19 pandemic, you may sign your own Consent form before you arrive at our office. 

New Patient Consent to Services

New Patient Intake Form

Please review our HIPAA Privacy Statement prior to your first appointment. You may request that we print the HIPAA Privacy Statement for you. Please notify us prior to your arrival if you would like us to print this notice for your records.

KMA HIPAA Notice for Patients

Financial Forms: Maryland law allows us to provide pre-payment discount packages for out of pocket medical services such as acupuncture and massage.  If you wish to take advantage of our pre-payment services, please print, read, and sign the following form prior to your arrival.  You will need to initial each paragraph to indicate that you understand the conditions of the package.

Prepaid Package Agreement

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