I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures on me (or on the patient named below, for whom I am legally responsible) by a licensed acupuncturist.
Initial here .
I understand the methods of treatment may include but are not limited to: acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), auricular acupuncture and Chinese herbal medicine.
I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting.
I understand that I should not move while the needles are being inserted, retained, or removed. I understand that I should not reinsert needles on my own, readjust or touch any medical equipment during the treatment.
I understand that I should not drink alcohol 2 hours before and after the treatment to avoid possible complications. I been informed that alcohol consumption together with herbal supplements can lead to serious health problems.
Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist below uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. The cupping process may leave minor red marks on skin known as petechiae. This marks will dissipate known as petechiae. This marks will dissipate Burns and/or scarring are a potential risk of moxibustion. The cupping process may leave minor red marks on skin known as petechiae. This marks will dissipate within a couple of hours or days and have no permanent effect.
I understand that while this document describes the major risks of treatment other side effects and risks may occur. I understand that the risk of infection is negligible when all needles are sterile.
The herbs and nutritional supplements (which are from plant, mineral, and animal sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs. I understand that I will not share my Herbal supplements with anybody else.
I will notify the acupuncturist who is caring for me if I am or become pregnant. I will notify the acupuncturist about recent change in my health condition, new Rx drugs or supplements intake.
I understand my patient records and patient information will be kept confidential and shared only when necessary to provide care and services, or by my authorization, or when required or permitted by law.
By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Patient’s Name:
Date Signed:
