I, (the undersigned), freely choose to undergo acupuncture treatments, which involve the insertion of special sterilized fine needles into the skin and underlying tissues at specific points for the purpose of alleviating pain and other clinical conditions. I know that there are no guaranteed results, and I am free to stop acupuncture treatment at any time.

I understand that while acupuncture is generally a safe method of treatment, certain adverse effects may result from treatment. These may be, but are not limited to infection (rare), perforation of organ, broken needles, fainting, some local bruising, redness, bleeding, tiredness and temporary pain or discomfort.

I state that I do not have the following conditions:
-Pregnancy
-Local infection
-Bleeding disorders (haemophilia/Hepatitis)
-Pacemaker
-Anticoagulant medications (ie. Coumadin etc.)
 
If I have any of the above conditions or medications I have listed them below.
I have read, or have had read to me, and completely understand the risks and benefits of acupuncture treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present conditions and for any future condition (s) for which I seek treatment.