Consent for Treatment
I, the undersigned, hereby consent to receive acupuncture treatment from the licensed practitioners of Stillpoint Acupuncture.
I am fully aware that the acupuncture needles are sterile and disposable and that no needle used to treat me has ever been used on another person.
I fully understand that there is no stated or implied guarantee of success or effectiveness of a specific treatment or series of treatments.
I understand that complications may result from acupuncture treatment. Among these possible complications are: bruising, fainting, numbness, weakness, nausea, hematoma, infection, burns, pain and discomfort, pneumothorax, and aggravation of present symptoms.
I understand that acupuncture and Chinese medicine is not a substitute for standard Western medicine, that certain health disorders may require allopathic diagnosis and treatment, and that I am free to seek allopathic medical advice and treatment at any time, either in lieu of or concurrently with acupuncture treatment.
I fully realize that I may withdraw from my treatment at any time.
I understand and agree to hold harmless, to indemnify and protect against court action the individual therapist as well as the management of this clinic, in the event of accidental injury on these premises.