Colorado Mandatory Disclosure and Informed Consent

PEAK Vitality LLC.

Ph: 720 504-8007
8101 E. Prentice Ave. Ste 100
Greenwood Village, CO 80111

The disclosure statement is in compliance with the State of Colorado, Department of Regulatory Agencies, Colorado Statute Title 12 Article 29.5. All rules and regulations set forth by the Department of Health are strictly adhered to, including proper cleaning, sterilization, and sanitation of equipment and office. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have any comments, questions, or complaints, contact the Acupuncturists Registrations Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The patient is entitled to receive information about the methods of therapy, the techniques used, and the durations of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registration in the Department of Regulatory Agencies.

Clinic Fee Schedule: (due at time of service)

Initial Consultation: $287

Re-Examinations: $87

Acupuncture: $120

Insurance: We do NOT accept or bill insurance.

24 Hour notice is required for change of appointments or cancellations. If you are unable to give 24 hour notice, we will do our best to fill your space, but if we are unable to do so, you will be charged a $30 fee for that appointment.

Practitioner Education and Experience:

Andrea Fowler, L.Ac. - Masters of Acupuncture from Northwest Health Sciences University in 2012.

  • Andrea Fowler received her Colorado Acupuncture License in 2016, and no license, certificate or registration of Acupuncture has ever been revoked or suspended.

Bruce Ayers, L.Ac. - Masters of Science in Oriental Medicine from Southwest Acupuncture College in 2004. Actively Licensed Respiratory Therapist since 1991.

  • Bruce Ayers received his Colorado Acupuncture License in 2005, and no license, certificate or registration of Acupuncture has ever been revoked or suspended.

Danny Kellams, L.Ac. – Masters of Science in Acupuncture and Oriental Medicine from the American College of Acupuncture and Oriental Medicine in 2009. Certified in Functional Medicine and Structural Alignment Acupuncture since 2015.

  • Danny Kellams received his Colorado Acupuncture License in 2012, and no license, certificate or registration of Acupuncture has ever been revoked or suspended.

Informed Consent:

I hereby request and consent to the performance of Acupuncture procedures by my acupuncturist, Danny Kellams. I have been informed that acupuncture is a safe method of treatment but that it may have side effects including discomfort, pain, dizziness, bruising, or numbness at the site of procedure. Unusual and rare risks of acupuncture include nerve damage, organ puncture including lung puncture, infection, and spontaneous miscarriage. Other side effects and risks may occur. If I suspect that I am pregnant, I will immediately inform the acupuncturist.

I have discussed the nature and purpose of my treatment with the acupuncturist named above. I understand that there are no guarantees regarding cure or improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture practitioner or other healthcare provider who may be more qualified to treat me outside of these facilities. I do no expect the acupuncturist to anticipate and explain all possible risks and complications, and I permit the acupuncturist to determine and/or alter the course of treatment which the acupuncturist judges to be in my best interest based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time.

I have read or have had read to me the above consent. I have also had the opportunity to ask questions about it’s content, and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment.

Signature of Patient of Person Authorized to Consent
Relationship or Authority of Representative
Date