I hereby voluntarily consent to receive acupuncture and Oriental Medicine treatment for my present and future health condition. I understand that treatment will be administered by Christie M. Savage, Licensed Acupuncturist (LAc
The treatments that will possibly be administered are described below. Acupuncture and Oriental Medicine Treatments That May Be Administered Acupuncture: This is a safe treatment involving the insertion of tiny sterile (and disposable) needles through the skin, which can produce a mild but temporary discomfort (usually achiness or soreness) at the acupuncture site. It can occasionally cause slight bleeding, and will rarely leave a bruise (not painful Other possible risks from acupuncture include dizziness and fainting. I will report to the LAc any dizziness or light-headedness that occur during or after an acupuncture treatment. Extremely rare risks of acupuncture (these have an extremely low incidence, especially when acupuncture is administered properly) include spontaneous miscarriage, nerve damage, organ puncture, and infection.
Heat Treatment with a TDP Lamp: This is used to warm an area of the body. Every precaution is taken to prevent overwarming, but the rare possibility of mild burns exists.
Moxibustion: Herbs burned on or near the skin to promote blood and qi circulation and local warming. Possible side effects are burns or blisters. I will inform the LAc immediately if the area becomes hot.
Cupping: This involves a localized suction produced by heating a small glass cup. There is a possibility of local bruising from the suction. Very rarely a slight burn or blister may appear due to the heat.
Gua Sha: Gua Sha is scraping on the skin in a small area using a smooth-edged instrument. This often results in bruising at the treated area. The bruising, which is not painful, usually resolves in 3-7 days.
Plum Blossom (or tapping): Multiple, mild needle pricks are applied in one area. Slight bleeding at the area is likely.
Electro-Acupuncture: A mild electric micro-current (similar to a TENS treatment) is used to stimulate the acupuncture points. A mild tingling or tapping sensation will be felt.
By signing below, I show that: -I have read, or had read to me, the information on this consent form, -I understand the possible risks and complications involved. I have had the opportunity to discuss this consent form with my Licensed Acupuncturist. I understand the above lists the major risks of acupuncture and the acupuncturist can not predict all possible outcomes. I understand that I can request more information at any time if desired. -I consent to receiving treatment that involves the above procedures. -I understand that I have the right to refuse or discontinue any treatment at any time. I understand that this refusal may affect the expected results.