Informed Consent for Acupuncture Care
(Please read carefully)
I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary, including; needling, moxibustion, cupping, gua sha, tui na, laser acupuncture, electro-acupuncture, and other techniques within the scope of practice of registered acupuncturists. The registered acupuncturist may perform these procedures in accordance with the Alberta Acupuncture Regulation. I have had the opportunity to discuss the nature and purpose of acupuncture care and other procedures or alternative care with the registered acupuncturist and/or with other office or clinic personal. I understand that results are not guaranteed. I further understand and I am informed that, as in all health care, in the practice of acupuncture, even though all the needles are pre-sterilized and disposable, there are some risks to treatment including but not limited to temporary soreness, bruising, blistering, nausea, fainting, bleeding, infection, pneumothorax and shock. I understand that it is possible to experience an exasperation (worsening) of my symptoms before I feel better. I understand that fainting is a possible reaction to acupuncture, and I agree to eat a meal before my treatment to reduce this risk. I understand that eating before my treatment only reduces the risk and does not eliminate the risk of fainting. I understand that it is possible to have and emotional reaction to acupuncture. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications and wish to rely on the acupuncturist to exercise judgement during the course of the procedure which the acupuncturist feels at the time, based upon facts then known, are in my best interest. As for my part, I will not be afraid to ask questions and if I feel uncomfortable at any time with any part of my visit, I will inform my practitioner immediately. I have read the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedure(s). 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.