Informed Consent

I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. Care, treatment, and services provided by Kate Quinn Stewart, L.Ac. are not a substitute for care, treatment, and services provided by a licensed physician. It is expected that I am under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.

 

Acupuncture and Related Techniques

I understand that I am free to ask questions about any and all techniques to be used in my treatment, and I am free to decline to receive any particular technique at any time if I so choose.  I understand that I may be treated with one or more of the following techniques:

• Acupuncture, which involves the insertion of slim, sterile needles into the body at various depths and locations

• Acupressure, which involves massage at the site of acupuncture points

• Stimulation of acupuncture points with a very mild electrical current, applied either to the skin or to an acupuncture needle inserted in the skin

• Stimulation of acupuncture points with small, self-adhesive plasters used to affix a magnet or small bead to the skin

• Stimulation of acupuncture points with gentle vibration using a weighted tuning fork

• Application of heat to the skin using a heat lamp or the burning of an herb called moxa, also known as moxibustion

• A massage technique called gua sha, which may leave redness on the skin that can last for 1-5 days. Gua sha may also cause temporary tenderness in the area treated.

• Cupping, which promotes circulation and may produce a red / purple color on the area treated, which may last for 1-5 days

• The expression of a few drops of blood from an acupuncture point using a small, sterile lancet

• Aromatherapy, which involves the inhalation and/or topical application of essential oils

• Chinese Herbal Medicine in the form of raw herbs, teas, tinctures, pills, or topical applications

• Instruction on food selection, breathing, movement, and other self-care practices based on Chinese Medicine principles

 

Chinese Herbal Medicine

The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that are recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy or in the case of significant changes in my health condition. I will notify my acupuncturist if I am, or become, pregnant, or if I am nursing, or if I have significant health changes, a new diagnosis, or new prescription medications. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over the counter). 

I understand that the herbs may need to be prepared and the teas, tinctures, pills, or topical preparations should be consumed/applied according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. Some possible side effects of taking herbs are: nausea, gas, stomachache, vomiting, liver or kidney damage (very rare), headache, diarrhea, rashes, hives, and tingling of the tongue. I will immediately notify my acupuncturist of any unanticipated or uncomfortable effects associated with the consumption of the herbs.

 

Infectious Disease Risk / Prevention

I understand that my acupuncturist uses only sterile, single-use, disposable needles and follows universally prescribed precautions to prevent the transmission of infectious disease.

I am informed that Kate Quinn Stewart has implemented preventative measures intended to reduce the spread of COVID-19 and complies with guidelines for infection control issued by the Centers for Disease Control and the local health department. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to Kate Quinn Stewart to proceed with providing care.

 

Risks / Possible Side Effects of Treatment

I understand that in some cases acupuncture may result in certain mild side effects including local bruising, slight bleeding, dizziness, light-headedness, temporary pain or discomfort and/or temporary aggravation of symptoms existing prior to treatment. Uncommon risks of acupuncture include nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although my acupuncturist uses sterile, disposable needles and maintains a clean and safe environment.

 

Communication During Treatment

I am encouraged to communicate with my practitioner about what I experience during the treatment and to ask any questions that I may have about the treatment.

If I experience dizziness, faintness, nausea, sudden sweating, or shortness of breath during the treatment, it is my responsibility to tell my acupuncturist immediately.  (These symptoms are rare and are most often caused by anxiety or low blood sugar.)

If I experience any pain, discomfort, or other adverse effects, it is my responsibility to immediately inform my practitioner.

I understand that it is my responsibility as a patient to inform my acupuncturist about all aspects of my health and, as treatment progresses, to inform my practitioner of changes that occur. 

 

Patient Responsibilities

I acknowledge that I am ultimately responsible for my own health and self-care.  Making healthy lifestyle choices can substantially support my healing process and enhance the outcome of the acupuncture treatments I receive.

I take responsibility for the outcomes I experience when implementing advice or suggestions given by my acupuncturist.  I will use my best judgment in determining whether a particular practice or self-care technique is safe and beneficial for me.

 

Treatment Outcomes

I understand that each individual responds uniquely to treatment and, for this reason, my practitioner cannot guarantee the outcome of treatment.  Some individuals experience total or partial relief of their symptoms after the first few treatments.  Others notice a steady, gradual improvement.  Occasionally, some people notice that their symptoms seem to worsen briefly before they improve.  I agree to share my responses with my acupuncturist at each follow-up so that my treatment plan can be adjusted accordingly.

 

By voluntarily signing below, I confirm that I have read the above consent to treatment, that I have been informed about the risks and benefits of acupuncture, Chinese herbal medicine, and related treatment techniques, and that I have had an opportunity to ask questions. I hereby consent to receive treatment as described above. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

To sign this form, please draw your signature in the box either by using the mouse or trackpad on your computer, or by using your finger on the touchscreen of your phone or tablet.

By initialing after each of the following statements, you acknowledge and agree to Nurturing Spirit Acupuncture's Patient Policies:

Appointments missed, cancelled, or rescheduled with less than 24 hours notice will incur a fee for the full cost of the appointment. If another patient can be found to fill the appointment, the missed appointment fee will be waived.

In any of the following circumstances, please cancel your appointment and reschedule for a later date. If you need to cancel with less than 24 hours notice due to contagious illness, the missed appointment fee will be waived.

• You have cold- or flu-like symptoms

• You or someone in your household has symptoms of COVID-19

• You or someone in your household has been exposed to COVID-19

• You or someone in your household are awaiting COVID-19 test results

• You or someone in your household has had a positive COVID-19 test result and you have not yet been medically cleared as no longer contagious

• You are having other symptoms of contagious illness

If you learn that you have been exposed to COVID-19, begin to experience symptoms of COVID-19, or test positive for COVID-19

AND

You have visited my office within the past 14 days,

Please contact me immediately so that I can take appropriate precautions.

During the time of the COVID-19 pandemic, all patients must wear a mask at all times while in the office, including for the duration of their acupuncture treatment.

In order to preserve the peaceful environment and receive a more relaxing treatment, please silence your cell phone during your treatment.

If you move or change phone numbers or email addresses, please inform me so that I am able to reach you in the event of unforeseen scheduling changes, inclement weather, etc. 

Nurturing Spirit Acupuncture does not submit insurance claims. A medical receipt can be provided, which you can submit directly to your insurance company for reimbursement. It is the patient’s responsibility to ascertain the terms under which the insurer will reimburse, and Nurturing Spirit Acupuncture makes no guarantees of reimbursement. Rules regarding whether acupuncture is covered, for how many treatments, and for what health conditions vary from one insurance plan to another and are at the discretion of the insurer. Payment is due regardless of the patient’s ability to obtain reimbursement.