Aurora Chiropractic Acupuncture Informed Consent
I hereby request and consent to the performance of acupuncture treatments and other complementary medicine procedures including various modes of physio-therapy on me (or on the patient named below, for whom I am legally responsible) by Dr. Miranda Neubauer, DC.

I understand that methods or treatment may include, but are not limited to, acupuncture, cupping, and/or electrical stimulation.

I have had the opportunity to discuss with Dr. Miranda Neubauer the nature and purpose of acupuncture treatments and other procedures.

Acupuncture attempts to normalize physiological functions, to modify the perception of pain, and to treat certain diseases or dysfunction of the body. I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances reported of spontaneous miscarriage and pneumothorax. There may be some bruising after cupping.

I do not expect Dr. Miranda Neubauer to be able to anticipate and explain all risks and complications. I will rely on the acupuncturist to exercise judgement during the course of the procedure, which the acupuncturist feels at the time, based upon the facts then known, is in my best interests.

I understand the clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content. By signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
PACEMAKER: Do you now have an artificial pacemaker? (a medical device to regulate heart beat) *
Your answer
CHRONIC DISEASES: Do you now have any chronic (or long term) diseases? Please list if so. *
Your answer
CONTAGIOUS DISEASES: Do you now have any contagious (or infectious) diseases? Please list if so. *
Your answer
BLEEDING DISORDERS: Do you now have any kind of bleeding disorder? Please list if so. *
Your answer
ALLERGIES: Are you now allergic or hypersensitive to any foods, drugs, or medications? Please list if so. *
Your answer
FEMALE PATIENTS ONLY: Are you now pregnant, or could you potentially become pregnant? *
Patient's Name *
Your answer
Date: *
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