|
Patient Name_______________________________________________________________ I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or on the named patient below for whom am legally responsible) by the acupuncturist named below and / or other licensed acupuncturist who now or in the future treat me while employed by, working or serving as back - up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic whether signatories to this form or not. I understand that the methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, Oriental Massage, Oriental herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness, or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some of the possible side effects of taking herbs are nausea, gas stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, 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, or have had read to me, 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 from to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. PATIENT SIGNATURE______________________________________________Date________________ (Or patient representative, Indicate relationship, if signing for patient) OFFICE SIGNATURE_______________________________________________Date:________________ |
| Village Center for Wellness - 5406 Village Road, Long Beach, CA 90808 - (562) 420-1585 Email: info@VillageCenterForWellness.com |