Acupuncture Consent

Read the following information carefully. Ask your practitioner if you have any questions or if there is anything that you do not fully understand.

Acupuncture is a form of therapy in which fine needles are inserted into specific points of the body. Only single-use, sterile and disposable needles are used in this practice

Acupuncture is generally safe. Serious side effects are rare and occur in less than 1 per 10,000 treatments. The risks associated with your particular procedure include:

General Side effects from acupuncture:

Drowsiness is a side effect of the procedure. This generally is very brief, if you are affected you are advised not to drive. A brief period of rest prior to leaving the facility is recommended.

Minor bleeding or bruising can occur in 3% of treatments.

Pain can occur during approximately 1% treatments.

During the 1st or 2nd treatment, certain patients can experience nausea, cold perspiration,malaise, light headedness and in extreme situations fainting.

Medication use and acupuncture:

Certain medications may retard your acupuncture response, including inhaled and oral steroids, phenytoin and carbamazepine.

Recreational drugs, especially marijuana also interferes with acupuncture response. Alcohol use before or within 24 hrs of procedure can impede acupuncture input.

Acupuncture treatment responses:

1. Gradual progressive improvement in your symptoms

2. Marked improvement of your symptoms followed by a gradual return to the presenting condition

3. Marked exacerbation of your symptoms, followed by a gradual return to your presenting condition.

4. No Response to the acupuncture treatment.

In general the 1st 3 responses are actually considered favorable and can be modified to improve your response with subsequent treatments. Certain patients will not respond to the acupuncture inputs, if no response is obtained after 3 sessions it may be recommended that acupuncture therapy be discontinued and further medical evaluation be performed.

In addition to your general medical history it is important that you let your practitioner know if:

You have ever experienced a fit, faint or funny turn

You have a pacemaker or any other electrical implants

You have a bleeding disorder

You are taking any anti-coagulants, such as warfarin, Coumadin, plavix, aspirin.

If you have damaged heart valves or have any other particular risk of infection.

You are being treated for or have any known blood bourne infections such as Hepatitis B, Hepatitis C, HIV etc.

Post acupuncture treatment recommendations:

You should rest the remainder of the day and avoid overexertion. It is recommended that you abstain from vigorous physical activity, avoid heavy meals, excessively rich or sweet food and drink. It is also recommended that you avoid very hot, very cold alcoholic beverages and sexual activity for the remainder of the day of treatment. Extremes can distract from the integration, duration and depth of the acupuncture treatment.

Statement of Consent

I confirm that I have read and understand the above information. I consent to having an acupuncture treatment. I understand that I can refuse treatment at any time and that I have informed my practitioner of any important medical history

DISCLAIMER: By typing your name, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.