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EASE ACUPUNCTURE WELLNESS GROUP

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.  

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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