Retreat Acupuncture Health Fair Consent Form
I consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine by the acupuncturists at Retreat Acupuncture. 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. Acupuncture attempts to normalize physiological functions, to modify the perception of pain, and to treat certain diseases of dysfunctions of the body. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that the herbs need to be prepared and the tea consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify the acupuncturists at Retreat Acupuncture, of any unanticipated or unpleasant effects associated with the consumption of the herbal teas. I will notify the acupuncturists at Retreat Acupuncture if I am or become pregnant. I do not expect the acupuncturists at Retreat Acupuncture, to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the named practitioner to exercise judgment during the course of treatment 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. By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment. I have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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.
Consent to Participate
I acknowledge and agree that I am voluntarily participating in a health fair screening, consultation and treatment. My involvement is as a participant and not as a patient. I further acknowledge and understand that the screening is limited in nature and is not a substitute for seeking medical treatment or follow up with a health care provider.
Types of Screening
I acknowledge and understand that the health fair is offering the following screenings: Personal health consultation, auricular examination, auricular press seeds, auricular acupuncture, pulse diagnosis, and tongue diagnosis.
Consent for Auricular Acupuncture and Press Seed Risks
I acknowledge and understand that I may experience slight pain, bleeding or a bruise at the site of acupuncture or press seeds.
I understand that Retreat Acupuncture will maintain the confidentiality of the screening results and follow HIPAA . By signing this form, I acknowledge that I’ve been given the opportunity to review this notice.
HEALTH FAIR PARTICIPANT ACKNOWLEDGMENT:
My signature below indicates that I have read, or have had read to me, and understand the contents. I believe that I have the knowledge upon which to base consent to participate in the health fair. All questions have been answered to my satisfaction. I hereby give consent to all screenings, consultations and treatments.
Signature (typing in your name will act as an acknowledged signature)
Date of Birth
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