Auricular Therapy Consent Form
Auricular Therapy Informed Consent to Participate and Release Form for Vanessa Ruiz, PLLC and Yoga Nirvana, LLC
I hereby request and consent to auricular therapy within the scope of practice of acupuncture for myself (name listed below) by Dr. Vanessa Ruiz. I understand that auricular therapy is a generally safe method of treatment that involves the insertion of ear seeds in the auricular region. I acknowledge that it may occasionally have some side effects including bruising, numbness, tingling or pain near the ear seeds lasting several days, as well as dizziness or fainting. Unusual risks of acupressure include spontaneous miscarriage and nerve damage. Emotional release and regression to past traumatic events may also result from any or all aspects of treatment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur not listed above. As with any health related treatment, I understand that it is impossible to accurately predict how any one person may respond to treatment and I acknowledge that there may be other effects not listed on this consent form. I understand that auricular therapy is not a replacement for diagnostic medical procedures. This healing session is not intended to treat or diagnose a condition. By signing below, I show that I have read, the above consent to treatment, have been told about the risks and benefits of auricular therapy and have had an opportunity to ask questions. I intend this consent and release form to cover this and for any future events for I participate in for auricular therapy.I hereby agree to indemnify and hold harmless Dr. Vanessa Ruiz, Vanessa Ruiz PLLC and Yoga Nirvana, LLC from any loss, liability, damage, judgement awards or costs, including court costs and attorneys╩╗ fees that may incur due to my participation in said therapy or subrogation suits or claims, whether caused by the negligence of Releasees or otherwise. I have carefully read this form and fully understand its contents. All information I have provided in any and all intake forms is true. I am aware this is a release of liability, a waiver of claims, an agreement not to sue, an indemnity, and a contract between myself and the Releasees described herein.
By typing my name below, I willfully agree to the above.
Type Name and Date
I give my consent to participate in auricular therapy
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