I (or the substitute decision-maker listed below) hereby request and consent to the performance of acupuncture treatments and other Traditional Chinese Medicine procedures by Kirsten Carson.
These methods may include but are not limited to: acupuncture, moxabustion, cupping, bloodletting, electro-stimulation, cupping, Tui Na (Chinese Massage), Gua Sha (Scrapping), Chinese herbal medicine and nutritional counseling.
I understand that I have the right to withdraw my consent to the treatment at any time. I acknowledge that I understand the following regarding my treatment: -the nature of the treatment -the expected benefits of the treatment -the material risks and side effects of the treatment (include but are not limited to: bruising, minor
bleeding, fainting, pain or discomfort.
This includes possibly aggravation of symptoms existing prior to treatment. Rare problems have been reported such as: joint infection, nerve damage, pneumothorax and needle breakage) - alternatives to having the treatment & consequences of not having the treatment
I acknowledge that my Traditional Chinese Medicine Practitioner or Acupuncturist cannot guarantee the results of the proposed treatment. I shall be responsible for consulting the necessary physician(s) before seeking care from Kirsten Carson. I further understand the acupuncturist makes no claim about curing my condition. I acknowledge that I have informed my Traditional Chinese Medicine Practitioner or Acupuncturist about my relevant health history, including whether I have any allergies, implants, major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases.
I acknowledge that I have asked any questions I may have and received answers I understand. By signing this form, I give my informed consent for the treatment &/or plan of treatment.