Informed Consent for Acupuncture Treatment and Care

Janice Poloway, L.Ac.
Evolution Acupuncture + Holistic Medicine
#303, 1532 Emerson Street, Denver, CO  

I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures, including nutritional counseling for me (or for the  patient named below, for whom I am legally responsible) by the below named licensed acupuncturist and/or other licensed acupuncturist who now or in the future treat me while employed by, working or associated with or serving as a back-up for the treating acupuncturist named below, including those working at this office/clinic or any other office or clinic.

I understand that methods of treatment may include, but are not limited to, acupuncture, acupressure, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), gua sha, Chinese or Western herbs, nutrient supplementation, and nutritional counseling.

I have had the opportunity to discuss with the acupuncturist named below and or with other office or clinic personnel the nature and purpose or acupuncture treatments and other procedures.

Acupuncture has the effect to normalize physiological functions, to modify the perception of pain, and to treat certain diseases or dysfunctions of the body. I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising, tingling near the needling sites that last a few days. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping or gua sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture including pneumothorax (lung puncture). There have been very rare instances of reporting fainting and infections.

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 and holistic medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastro-intestinal upset or allergic reactions to the herbs I will inform the acupuncturist.

 I do not expect the acupuncturist to be able to anticipate and explain all risks and complications, and I wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the acupuncturist feels at the same time, based upon the facts then known, is in my best interests. I do not expect a guarantee on the results of my treatment.

 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.

I have read or have read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-name procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions (s) for which I seek treatment.