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The Teal Center for Therapeutic Bodywork, Ltd.
Acupuncture & Chinese Herbal Medicine Informed Consent
Please take the time to read this form, which will provide you with some basic information about acupuncture.
Important Things to Keep in Mind Regarding Acupuncture Treatment:
Acupuncture and Related Techniques:
I understand that I may be treated with one or more of the following techniques. I understand that not all techniques are indicated for every person or condition, and I am free to ask my practitioner for more information about techniques to be used in my treatment.
I understand that my acupuncturist uses only sterile, single-use, disposable needles and follows universally prescribed precautions such as clean needle technique and hand washing to prevent the transmission of infectious
I understand that in some cases acupuncture may result in certain side effects, including local bruising, slight bleeding, dizziness, fainting, minor burns resulting from the use of heat therapies, temporary pain or discomfort, and/or temporary aggravation of symptoms existing prior to treatment.
Patient Responsibilities 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. If I experience any pain, discomfort, or possible adverse side effects, it is my responsibility to immediately notify my practitioner. 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.
Confidentiality I understand that the confidentiality of my file and the information I share in the course of treatment will be honored and preserved. I acknowledge that my practitioner is ethically and legally required to report certain information pertaining to the abuse of minors and elders or serious threats of violence.
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 before they improve. I agree to share my responses with my acupuncturist at each follow-up visit so that my treatment plan can be adjusted accordingly.
By signing this informed consent form, I acknowledge that I have read the information above carefully and that I consent to receive acupuncture treatment.
I, First Name* Last Name* , give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.
I understand that, according to OSHA, massage and bodywork represent a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.
I also understand:
1. That massage therapy and/or acupuncture
2. That the massage therapists and/or acupuncturists
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.
If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.
I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
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