Acupuncture
Indemnity Form
Please complete and submit before your session
Sign in to Google to save your progress. Learn more
Email *
Treatment Description
Acudetox is a specialized form of acupuncture and is performed by placing five thin, sterile, single-useneedles in your ears. The needles are generally left in place for 35 – 45 minutes. Treatment time may need to bealtered for clinical or training purposes. State Licensed Acupuncturists, Licensed Auricular DetoxificationSpecialists (ADSes) and/or others persons training to become Auricular Detoxification Specialists (ADSTrainees) administer the treatments.
I hereby voluntarily consent to be treated by acupuncture, and in particular the NADA acudetox protocol. I understand I may be treated with needles and/or small seeds taped to my ears.I have not been guaranteed any success concerning the uses and effects of acudetox. I understand I am free to discontinue treatment at any time. *
Required
Possible Side Effects/Healing Reactions
I understand that acupuncture may result in certain side effects, including local bruising, slight bleeding,fainting, temporary pain and discomfort, and temporary aggravation of symptoms existing prior to treatment.Conventional medical therapy also may be indicated, either in response to an emergency or as deemed necessary at the discretion of a licensed physician. *
Medical Referral
I understand if there is a worsening of my ailment or condition or if a new ailment or condition arises, that I should consult a licensed physician. I also understand that if I am currently under a physician’s care I should continue as long as my physician and I deem it necessary and that my acudetox providers do not recommend altering medications or other therapies without first consulting my personal physician or provider. *
Infectious Disease/Clean Needle Procedures
Questions *
Yes
No
Pacemaker?
Pregnant?
Name and Surname *
Date
MM
/
DD
/
YYYY
Cell phone number *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms