Informed Consent to Acupuncture Treatment
I consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine in Ease Acupuncture P.C. and Wellness Group. I have discussed the nature and purpose of my treatment with the provider.
I understand that methods of treatment may include but are not limited to acupuncture, cupping, electrical stimulation, Tui Na therapy / acupressure massage, low level laser treatment and LED therapy.
I have been informed that acupuncture is a safe method, but that it may have side effects including bruising, numbness or tingling near needling sites that my last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. The herbs and nutritional supplements 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 and tingling of the tongue. I will immediately notify the provider of any unanticipated or unpleasant effects associated with the consumption of the herbal teas. I will notify the provider if I am or become pregnant. I have been given no guarantee or assurance of specific results. I understand the clinical provider may review my patient records, but all my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read the above 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 my visits for my present condition and for any future condition(s) during my visits to Ease Acupuncture Wellness Group and their affiliates.