I, the undersigned, understand that methods of treatment used in this practice may include, but are not limited to, acupuncture, moxibustion, cupping, guasha, electrical stimulation, herbal therapy, tuina massage, qigong, reiki, and nutritional counseling.

I understand that these are all safe methods of treatment. Potential risks include temporary bruising, swelling, bleeding, numbness and tingling, and soreness at the needling site that may last a few days. Unusual risks of acupuncture include dizziness, fainting or nerve damage. Infection is rare and this clinic uses alcohol and sterile disposable needles and maintains a safe and clean environment. Potential risks of moxibustion therapy are burns, blistering, or scarring. Temporary bruising or redness lasting a few days is a common side effect of cupping and guasha. I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments.

I will notify the acupuncturist should I become pregnant so that my practitioner can avoid points and herbs that could induce miscarriage.

I understand that herbal and nutritional supplements recommended to me by my acupuncturist are safe in the recommended doses. Possible side effects of herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I understand that I must stop taking any herbs and notify my acupuncturist as soon as I experience any discomfort or adverse reactions.

I understand that this clinic complies with required Privacy Practices and all my records will be kept confidential. If it becomes necessary to share my health information, this will be handled in accordance with the customary Privacy Practices.

I understand that I can discuss risks and benefits further with my practitioner before signing if I choose. However, I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her judgment in my best interest during the course of treatment, based upon the facts then known.

I recognize that scheduling an appointment involves the reservation of time specifically for me, and that consequently, a minimum of 24 hours notice is required to reschedule or cancel an appointment. Unless otherwise agreed to in advance, the full fee will be charged for sessions missed without such advance notification. I understand that most insurance companies do not reimburse for missed sessions.

In submitting this form, I, or my parent, acknowledge any inherent risks, and give my consent for treatment, payment and healthcare operations received, incurred or carried out at this practice.