Acupuncture Informed Consent

I hereby request and consent to the performance of the following on myself (or the patient named below, for whom I am legally responsible) by the practitioner: acupuncture and other Chinese medical procedures including diagnostic techniques such as questioning, pulse evaluation, palpation on a variety of areas of my body, observation, range of motion, muscle and orthopedic testing; modes of manual or physical therapy such as bodywork, manipulation of viscera, heat and/or cold therapy and electrical and/or magnetic stimulation; cupping and/or moxibustion; the prescription of herbal and holistic medicines as well as dietary supplements; dietary recommendations; at home stretches; and healthy lifestyle recommendations. *

I understand I have opportunities to discuss with the Licensed Acupuncturist the nature and purpose of acupuncture and Chinese medical procedures. Although I am aware that acupuncture and the other procedures used in Chinese medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied. *

I understand and am informed that, as in the practice of conventional Western medicine, in the practice of Chinese medicine there are some risks to treatment. I understand that although these risks are unlikely to occur, they are possible. I understand that these risks include, but are not limited to: bleeding, bruising, pain or other strong sensation at the location of where a needle is inserted or radiating from that location, nerve pain, burns, aggravation of current symptoms, appearance of new symptoms, and general aches. Other rare but possible risks include pneumothorax (punctured lung), puncture of other organs, sprains, strains, disc injuries and strokes. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment, during the course of my treatment, as the practitioner feels at the time, based on the facts then known, to be in my best interest. *

I have read, or have had read to me, this informed consent form. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures and conditions of treatment. 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 from the Acupuncturist. *

I will notify the Acupuncturist should I become pregnant or if I am in the process of trying to become pregnant so my practitioner can avoid points that could induce miscarriage. *