Acupuncture Informed Consent to Treat
Email *
Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.
Clear selection
I understand that I am the decision-maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by licensed acupuncturist Julie Meyer, and/or by another acupuncturist working or associated with or serving as back-up for the acupuncturist named herein. I understand that methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine and nutritional counseling.
Clear selection
I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but as with all types of interventions, there are some possible risks to care including but not limited to: bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion, cupping, or the use of a heat lamp. Unusual risks that have been reported in the literature include nerve damage and organ puncture. Infection is another possible risk although the clinic uses sterile, single-use, disposable needles and maintains a safe and clean environment.
Clear selection
I understand that physical distancing to avoid COVID-19 or other viral infections is not possible during an acupuncture treatment and I accept the risk of choosing this treatment option anyway. I have been informed that my practitioner was vaccinated against the COVID-19 virus but not all patients who have been in the clinic at one time have been vaccinated. I agree to wear a mask in the office and to cancel and reschedule my appointment if I have any covid-like symptoms or known exposure. I understand that exposure to Covid or another virus in a closed room, even if vaccinated, remains possible. I accept that risk.
Clear selection
I will immediately notify the practitioner of any unanticipated or unpleasant effects associated with the consumption of herbs. I will notify the practitioner if I am pregnant, nursing, or plan to become pregnant. I will notify the practitioner of any changes in my health, medications, supplements or other medical care. If I develop any covid-like symptoms before my appointment I will call, text or email to reschedule. I understand that as with all healthcare, results are not guaranteed, and there is no promise to cure.
Clear selection
I understand that I have other treatment options outside of acupuncture care, and I have the right to obtain other healthcare as I see fit. By voluntarily signing below, I confirm that I have read or have had read to me the above consent to treatment and understand the risks and benefits of acupuncture and other procedures. I have had the opportunity to ask questions. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
Clear selection
I attest that by using the keyboard of the computer I sign my name with the same authority as if I used a pen on paper. Please leave your signature and the date below *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy