By signing below, I do hereby request and voluntarily consent to be treated, or give permission for my child/ward to be treated, with acupuncture or other healing techniques, health coaching, nutritional supplements, and/or herbal formulas. This agreement applies to any any employee or back-up provider serving the patient at Healthpointe Acupuncture & Wellness.
I understand that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic. I certify that I have informed the practitioner of all medications being used and all known physical, mental, and medical conditions, including possible pregnancy. I certify that I will notify the practitioner of any changes to these medications or health conditions.
Acupuncture & Other Techniques: I understand that acupuncture is performed by the insertion of needles through the skin with or without electrical stimulation; and/or by the application of heat to the skin at certain points on or near the surface of the body. Other techniques may also be used, which may include but are not limited to: tuina, cupping or gua sha. I am aware that acupuncture is a generally safe method of treatment, but that it may have some side effects. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that if I receive direct moxabustion as part of therapy, there is a risk of burning or scarring from its use. Unusual and rare risks include nerve damage, organ puncture, and infection. I understand that I may refuse any technique or treatment offered. I understand that clean needle procedures are used in this office, and that prepackaged, sterilized needles are used once and then disposed of as medical waste.
Health Coaching: I understand that dietary/lifestyle changes, nutritional supplements and/or herbal formulas may be recommended to me as part of treatment. I understand that I am not required to follow these recommendations. I agree to follow the directions for administration and dosage if I do choose to take the recommended supplements/herbs. I am aware that certain adverse side effects may result from taking these supplements/herbs. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call Healthpointe Acupuncture as soon as possible.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.
I have carefully read and understand all of the above information and understand the possible risk involved. I have felt free to ask any questions, and it has been satisfactorily explained to me. I understand that no guarantees concerning the use and effects of these methods are given to me and I may discontinue treatment at any time.