I understand that acupuncture is performed by the insertion of fine sterile needles through the skin atcertain points on thebody in an attempt to treat bodily dysfunction or disease, to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certainadverse side effects may resultfrom this treatment. These mayinclude, butare not limitedto:local bruising, minorbleeding, fainting, painor discomfort, the possible aggravation of symptoms and,very rarely, organ puncture, nerve damage or infection.
I have had an opportunity to discuss with the doctor the nature, purpose, and risk of chiropractic adjustments, acupuncture, and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed.
I have read or have had read to me the above explanation of the chiropractic adjustment, acupuncture and related treatment. By signing below, I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the treatment recommended. Having being informed of the risks, I hereby give my consent to that treatment. 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.