I hereby request and consent to the performance of herbal treatment and/or acupuncture and allied modalities (moxibustion, cupping, gua sha) on myself or the patient named below, for whom I am legally responsible, by Jonathan Hadas Edwards, LAc.
I understand that herbal treatment may include Western and Chinese medicinals in tincture, powder, tablet, capsule, infusion and/or decoction form.
I understand that the herbs and nutritional supplements (which are from plant, mineral, and occasionally from animal sources) that will be recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. I understand that idiosyncratic reactions can sometimes occur and that possible side effects include nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I understand that the herbs need to be consumed according to the instructions provided.
I understand that acupuncture carries a small risk of bruising, fainting, skin reactions, and other adverse effects. I understand that in extremely rare cases, acupuncture has resulted in nerve damage and pneumothorax, and that every effort will be taken to avoid any such occurences.
I understand that cupping can result in skin discoloration lasting several days, and can occasionally cause blistering. I understand that moxibustion carries a risk of burns.
I agree to notify Jonathan if I am currently or if I become pregnant, or if I have a bleeding disorder. I agree to notify Jonathan in the event of any adverse effects associated with treatment or with the consumption of the herbs dispensed or recommended. I will notify Jonathan of any significant changes in my health, or new diagnoses by my primary care physician.
By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment and have had an opportunity to ask questions in person or via email.
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.