I hereby request and consent to the performance of Acupuncture treatments and other Traditional Chinese Medicine (“TCM”) treatments on me by Contrast Healthcare & Acupuncture.
I understand that Contrast Healthcare & Acupuncture will keep a record of all treatments I receive and that this record will be confidential and will not be released to others unless directed to do so, or as prescribed by law.
I understand that TCM Practitioners will answer any questions I have to the best of their abilities, but that the results of TCM are not guaranteed.
I intend this Consent Form to cover the entire course of treatment for my present condition, and understand that I am free to withdraw my consent and discontinue participation in these procedures at any time with notice to Contrast Healthcare & Acupuncture.
Acknowledgement & Release
- I have provided Contrast Healthcare & Acupuncture with a full medical history, including but not limited to, a full description of all previous healthcare treatments received, any allergies, any prescription medicines taken for the last year, any surgeries and any general health complaints or complications.
- I have informed Contrast Healthcare & Acupuncture that I currently do not believe I am pregnant.
- I understand that the advice and treatment I receive from Contrast Healthcare & Acupuncture is based on the information I provide.
- I understand that the TCM treatments offered by Contrast Healthcare & Acupuncture may include, but are not limited to Acupuncture, Cupping, Electro-Stimulation, Diet Therapy, Gua Sha, Herbal Medicine, Lancing, Moxibustion and Tui Na.
- I understand Contrast Healthcare & Acupuncture makes no guarantees as to the use and effects of TCM on each individual, and in particular that Contrast Healthcare & Acupuncture does not warrant the quality of the Herbal Medicines used.
- I have been informed that generally Acupuncture, Cupping, Electro-Stimulation, Diet Therapy, Gua Sha, Lancing, Moxibustion and Tui Na are safe, but that they may have side effects that include but are not limited to, bruising, numbness or tingling, minor bleeding, broken needles, dizziness and/or fainting. Some very rare risks of acupuncture include but are not limited to, infection, spontaneous miscarriage, nerve damage, burns and/or scarring and organ puncture.
- I have been informed that Herbal Medicine is generally safe but that some possible side effects may include but are not limited to, nausea, gas, allergic reaction, acid reflux, stomachache, vomiting, headache, diarrhea, anaphylaxis, rashes, hives, and tingling of the tongue.
- I understand that Herbal Medicine involves the use of herbal substances which are comprised from plant, animal and mineral sources, and that any Herbal Medicine I am prescribed shall only be used in the methods as prescribed by Contrast Healthcare & Acupuncture.
- I understand that Herbal Medicines can be toxic in large doses, and that some Herbal Medicine may be inappropriate during pregnancy.
- I agree to immediately notify Contrast Healthcare & Acupuncture should I notice any symptoms that I believe are related to TCM or treatments I received at Contrast Healthcare & Acupuncture.
- I allow Contrast Healthcare and Acupuncture to share all of the information collected with all of the practitioners employed by Contrast Healthcare and Acupuncture.
- By agreeing to the performance of TCM as provided by Contrast Healthcare & Acupuncture, I hereby release Contrast Healthcare & Acupuncture as follows:
I hereby certify that I am at least 18 years of age, or at least 16 years of age and my parent or guardian has signed below, that I am suffering under no legal disabilities, and that I (or my parent or guardian) have read this document carefully, understand each term and provision in its entirety, have agreed to the terms freely and voluntarily. Having read the foregoing, I (or my parent or guardian) knowingly acknowledge my understanding of the risks set forth herein and knowingly agree to accept full responsibility for my own exposure to such risks.
Attention: this document affects your legal rights, including the right to sue, so please read carefully.