Acupuncture and Oriental Medicine Consent Form
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Jacalyn Brull L.Ac. or other licensed acupuncturists who may serve as back-up for this practice. I am aware that I have the right to decline any treatment technique for any reason at any time.
I understand that the methods of treatment at this practice may include, but are not limited to:
Acupuncture: the insertion of pre-sterilized, disposable needles through the skin into the underlying tissues at specific points on the body.
Electro Acupuncture: Small amounts of electricity to stimulate specific acupuncture points.
Infrared Heat: Applying heat generated by an infrared lamp over a specific area of the body.
Moxabustion: Indirect burning of an herbal compound on acupoints with a moxa pole or loose moxa.
Cupping: Cups made of glass or silicone are placed on the skin with a vacuum created by heat or a suction device.
Tui Na: Traditional Chinese medical massage and manual therapy.
Liniments, Oils, Plasters: Herbal formulas applied topically to the skin.
Nutritional Advice and lifestyle counseling: Includes diet, herbal and supplement recommendations.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some uncommon side effects, including bruising, numbness or tingling near the needling sites that may last a few days, or dizziness and fainting. Occasionally a treatment can produce a temporary flare up of symptoms, but these are almost always limited to no more than a few days. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax Infection is another possible risk; however, this practice uses sterile one- use-only needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxabustion and cupping. A bruised appearance is a common side effect of cupping and Gua sha.
I will notify the practitioner who is caring for me if I am or become pregnant, have a pacemaker, bleeding disorder, damaged heart valves, or a contagious disease.
I understand that the practice's staff may review my patient records and lab reports, but all of my records will be kept confidential and will not be released without my written consent. However, the practitioner shall be in alignment with state law and training to refer me to the emergency room or request consultation or written diagnosis from am licensed Physician, if I have a potentially serious disorder, such as cardiac conditions, including hypertension ; severe abdominal pain; acute neurological changes; unexplained weight loss or gain in excess of 15% of body weight in less than three months ; suspected fracture or dislocation ; or acute respiratory distress without previous history. I am herby advised to consult with my primary care physician on medical issues and that acupuncture is not substituting for appropriate medical advice and care form a medical doctor.