INFORMED CONSENT FOR ACUPUNCTURE
Please read carefully
I consent to the performance of acupuncture treatment and other procedures related to acupuncture if necessary including needling, moxibustion, cupping, acupressure, TuiNa, GuaSha and other
techniques within the scope of practice of Traditional Chinese Medicine. These procedures are to be performed by the registered acupuncturist.
I have had the opportunity to discuss with the registered acupuncturist on the nature and purpose of acupuncture care and other procedures. I understand that results are not guaranteed.
I understand that there is the possibility of temporary complications that may result from and acupuncture treatment, which include, but are not limited to:

• Minor bleeding or bruising
• Minor pain or soreness
• Nausea, weakness, fatigue, fainting, or aggravation of existing symptoms for a short time.

I understand that if there are any particular risk that apply to my case, my practitioner will stop the procedures and discuss these with me.
I further state that the following conditions don not exist in my current state of health and that I will immediately notify my practitioner of any changes regarding the following:

• Pregnancy
• Seizure disorder( Epilepsy)
• Elevated risk of infections
• Local infections
• Bleeding disorders
• Pacemaker

I authorized the clinic and its associated health professionals to collect my personal and medical information, I also understand that my personal and medical information is confidential and will only
be disclosed to third parties with my permission. In additon, I authorize the clinic and its associated health professionals to communicate with my family doctor and/ or referring doctor as deemed necessary for my beneficial treatment.
I have read the above consent. I have also had and opportunity to ask questions about the consent, and by signing below I agree to the above named procedure. This consent form covers the entire course of treatment for my present condition and for any future conditions toe be treated.