Nadine Shozuya, L.Ac.
2140 Artesia Blvd. Unit A.
Torrance, CA 90504
I hereby acknowledge that I have no insurance that covers services, and I understand that all services are payable when treatment is rendered.
I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be referred to by Nadine Shozuya and any emergency transporting that may be required thereto.
Patient or Guardian Signature:________________________________Date:__________