Consent Form

By checking the box below, I do hereby voluntarily consent to be treated with acupuncture and/or herbal medicines by Allison D. Suddard, L.Ac.. who is a licensed acupuncturist in the state of Colorado. I understand that acupuncturists practicing in the state of Colorado are not primary care providers.


Acupuncture:
I understand that acupuncture means the stimulation of certain points on the surface of the body by the insertion of needles through the skin to modify or prevent pain
perception and/or to normalize physiological functions in an attempt to treat disease or dysfunctions of the body. I understand that acupuncture treatment may include the use of moxibustion, electro-acupuncture, and/or acupressure. I have been made aware that certain adverse side effects may result which could include, but are not limited to: local bruising, minor bleeding, fainting, temporary pain or discomfort, and the possible temporary aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.

Moxibustion:
I understand that moxibustion means the therapeutic application of direct or indirect heat to the skin at certain points on or near the surface of the body. I have been made aware that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy.

Electro-Acupuncture: I understand that electro-acupuncture means the therapeutic use of weak electric currents to stimulate acupuncture points. I have been made aware that certain adverse side effects may result which could include, but are not limited to: electrical shock, temporary pain or discomfort, and the possible temporary aggravation of symptoms existing prior to acupuncture treatment. I understand that I may refuse this therapy.

Acupressure/Massage:
I understand that I may be given acupressure or Oriental massage as part of my treatment to modify or prevent pain perception and/or to normalize physiological functions in an attempt to treat disease or dysfunctions of the body. I have been made aware that certain adverse side effects may result which could include, but are not limited to: muscle soreness and the possible temporary aggravation of symptoms existing prior to the treatment. I understand that I may stop this
therapy if it is uncomfortable.

Chinese Herbs:
I understand that oriental medicinal substances may be recommended to me to modify or prevent pain perception and/or to normalize physiological functions in an attempt to treat disease or dysfunctions of the body. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I have been made aware that certain adverse side effects may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems that I associate with these substances, I should suspend taking them and call the acupuncture clinic as soon as possible.

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