I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures on me (or on the patient named below, for whom I am legally responsible) by a licensed acupuncturist.

I understand the methods of treatment may include but are not limited to: acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), bleeding and Chinese herbal medicine. I have had the opportunity to discuss with the above-named acupuncturist the nature and purpose of acupuncture treatments and other procedures.

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, with possible dizziness or fainting. Bruising is a common side effect of cupping. Burning, scarring or blistering of the skin are rare complications as a result of moxibustion or TDP lamp use. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). I understand that the risk of infection is negligible when all needles are sterile.

The herbs in raw, granules, pills (which are from plant, animal and mineral sources) that may be recommended are traditionally considered safe, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhoea, rashes, hives and tingling of the tongue.

I understand that the herbs need to be prepared and the herbal medicine should be consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately inform the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbal teas.

I will notify the acupuncturist who is caring for me if I am or become pregnant.

I will notify the practitioner about having a pacemaker or metal implants if applicable. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications, and I wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the acupuncturist feels, based on the facts then known, is in my best interests.

I agree that the practitioner might take the face, tongue pictures, do pulse check, abdominal check and meridian check, do video/audio record for TCM diagnoses, medical record purpose only. I understand the clinical and administrative staff may review my medical records and lab reports, but all my personal information in the record will be kept confidential and will not be released without my written consent. I understand that I can refuse treatment or any specific types or part of acupuncture and other TCM treatment methods at any time by informing the practitioner. It might not be refundable.

I have read, or have read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. 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.