Acupuncture Consent Form
Please review, initial, and sign. By entering your name and relationship to the patient, you have acknowledged and agreed upon the agreements presented herein. By signing this agreement electronically (rather than in hardcopy), your electronic signature will have the same legal effect as a handwritten signature.
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Informed Consent
Acupuncture is a skilled technique performed by a physician or therapist using a single-use, sterile filiform needle to penetrate the skin or underlying tissue to effect change in body conditions, pain, movement, impairment and disability.

Electroacupuncture is a modified form that uses two needles and a mild electric current passes between these needles during treatment.

Like any treatment there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for acupuncture treatment.

Risks of the procedure:

The most serious risk associated with acupuncture is accidental puncture of a lung (pneumothorax). If this were to occur, it may require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture, while rare, may require hospitalization.

Other risks may include but not limited to bruising, infection or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant issue trauma from acupuncture is unlikely.
Does the patient have any of the following absolute contraindications to acupuncture and/or electroacupuncture? *
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Does the patient have any of the following relative contraindications to acupuncture and/or electroacupuncture? *
Required
    I have read the above explanation of acupuncture. I have discussed it with Steven Casper, DC and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. *Patients/Legal Guardian: Please type your name below to consent to acupuncture. *
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