Medical Acupuncture Consent Form
Diagnosis and Treatment Consent
I, the undersigned, do hereby give my voluntary consent
for the administration of medical acupuncture, dry needling acupuncture
techniques and other relevant Chinese medical therapies.
Acupuncture and the dry needling technique have been
explained to me as a medical treatment performed by the insertion of
special sterilized fine needles with or without the application of
electrical stimulation through the skin into the underlying tissues and
muscles at specific points on the body for the purpose of alleviating
pain and treating other clinical conditions.
Ancillary techniques of acupuncture may include one or
more of the following:
-
Moxibustion -whereby herbal heat is applied to
specific acupuncture points
-
Cupping- whereby suction cups are applied to
specific points on the body or motion suction cups
-
Electro-acupuncture- whereby the needles are
electrically stimulating at various high frequencies to cause
relaxation of the muscles and analgesia of the area of pain
involved.
I have been made aware of the possibility of complications
which may result from these procedures. These include infection (rare),
bruising and bleeding into the tissues, pain and discomfort, weakness,
tiredness, fainting, nausea, aggravation of existing symptoms for a
short time, etc.
I state that I do not have the following conditions:
• Pregnancy
• Bleeding disorders
• Pacemaker
• Local infections
• Anticoagulants
If I have any of the above conditions, I have listed them
here: -------------------------------------------
I hereby certify that I have understood the above
authorization and the risks involved. All relevant questions which I
have asked have been answered.
| Patient Name: (print) ---------------------- |
Witness Name (print) ------------------------- |
| Patient Signature --------------------------- |
Witness Signature ----------------------------- |
| Date --------------------------------------- |
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