INFORMED COSENT TO ACUPUNCTURE TREATMENT
I consent to acupuncture treatments and other procedures associated with Traditional Oriental Medicine by the Licensed Acupuncturist named below. I have discussed the nature and purpose of my treatment with this person.
I understand that methods of treatment may include but are not limited to acupuncture, moxabustion, cupping, guasha, electrical stimulation and Tui Na (Chinese Massage).
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 to needling sites that may last a few days and dizziness or fainting. Bruising is a common side effect of cupping or guasha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this clinic uses sterile, disposable needles and maintains a clean and safe environment. Burns and/or scarring are potential risks of moxabustion. I understand that while this document describes the major risks of treatment, other side effects may occur.
The herbs and nutritional supplements (which are from plant, animal and mineral sources), which may be recommended are traditionally considered safe, 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, diarrhea, rashes, hives and tingling of the tongue. I will notify my practitioner of any unanticipated or unpleasant effects associated with the consumption of herbs.
I will notify my practitioner if I become pregnant.
I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on my practitioner to exercise judgment during the course of treatment which the practitioner thinks at the time, based upon the facts known to him, is in my best interests.
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 intended 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.