Each patient has the following rights:
The patient is allowed to receive information about the methods of therapy, the techniqus used, and the duration of treatment.
The patient is allowed to seek a second opinion from another healthcare professional or may terminate therapy at any time
In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Professions and Occupations immediately
The practice of acupuncture is regulated by the Deprtment of Regulatory Agencies. The Director of theDivision of Professions & Occupations may be contacted at:
Division of Professions & Occupations Acupuncturist Licensure
1560 Broadway, Suite 1350, Denver, CO 80202, (303) 894-7800
I confirm that I have carefully read and understand all of the above information and am fully aware of what I am signing at the end of this form. I understand that Thrive Community Acupuncture does not provide primary care, or Western (allopathic) medical care.
I hearby release Thrive Community Acupuncture and its employees and subcontractors from any and all liability that may occur in connection with the acupuncture, body work or herbal treatment I receive, except for failure to perform with appropriate medical care. I hereby give me consent to acupuncture, cupping, e-stim, and acupressure and any herbal/homeopathic treatment for my present condition and for any future condition(s) for which I seek treatment.
My signature at the end of this form indicates that I understand and agree to the above.
Our Practitioner's Education, Certification and Experience:
David Gorski, L.Ac., is licensed in the state of Colorado having graduated from Southwest Acupuncture College in Boulder, CO with their Masters Degree in Acupuncture.
I hereby request and consent to the performance of acupuncture by the acupuncturist as your clinic has on staff.
I have been informed that acupuncture is a safe method of treatment but that it may have side effects incuding discomfort, pain, dizziness, bruising, or numbness at the site of procedure.
Unusual and are risks may include nerve damage, organ puncture, infection, and spontaneous miscarriage. Other side effects may occur. If I suspect that I am pregnant, I will immeidately inform the acupuncturist.
During my appointment I will discuss the nature and purpose of my treatment with one of the acupuncturist(s) named above.
I understand that there are no guarantees regarding cure or improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture proactitioner or other healthcare provider who may be more qualified to treat me outside of these facilities.
I do not expect the acupuncturist to anticipate and explain all possible risks and complications, and I permit the acupuncturist to determine and/or alter the course of treatment as they judge to be in my best interests based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time.
I understand that it is always possible that a needle may accidentally be left in place or fall on my clothing after my tretment, and I understand that I am responsible for double-checking that all needles have been removed.
I have read or have had read to me the above consent. I have also had the opportunity to ask questions about its content, by calling (970) 282-8300 and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for my condition and for any future conditions for which I seek treatment.
I have futhermore been informed that Thrive Community Acupuoncture clinic's acupuncturists are not medical doctors and do not provide primary care medicine or diagnostic medical procedures. I understand, too, that if I think there is any possibility that I may be experiencing a serious health concern, or if I want someone knowledgeable to review my medical history with me, I need to see a primary care physician prior to acupncture treatment. I understand that, as a complementary care provider, Thrive Community acupouncture is pleased to communicate with my physician at my request.
I understand, acknowledge, and volunarily accept the risk associated with acupuncure services, use of your facilities, and I hereby release you (incuding, without limitation, personal, bodily or mental injury, property damage or economic loss), which may result form your acupuncture, cupping, or from taking herbs ordered by or recommended by the acupuncturist, my failure to disclose any pre-existing condition, limitation or sensitivity, or my famiure to inform my therapistof discomfort during my session.
My signature below indicates that I have given accurate information on this form and that I have read and agreed to the Colorado Mandatory Disclosure and Informed Consent form.