Consent to Treat and Liability Waiver Form
Please read and then sign & date on following page
24 hour notice is requested for change of appointment or cancellation, unless there is an emergency. A $15 fee will be charged for missed appointments or late cancellations.
Practitioner Certifications
Lauren Borowsky, Dipl O.M., L.Ac, LMT
*Master of Science in Acupuncture & Oriental Medicine from Five Branches University in Santa Cruz, California. Graduated 2010
*California Licensed Acupuncturist. 2010
*Nationally board certified as a Diplomate in Oriental Medicine by the National Certification Commission for Acupuncture & Oriental Medicine
*Licensed Massage Therapist in New York State and Nationally. 2000. *Craniosacral Therapy trainings 6 levels. 2007-2014 *Certified Yoga Teacher. 2006.
No license or certificate has ever been revoked or suspended.
I hereby request and consent to the performance of the following on myself (or the patient named, for whom I am legally responsible) by Lauren Borowsky: Acupuncture and other Eastern medical procedures including diagnostic techniques such as questioning, pulse evaluation, tongue evaluation, palpitation, observation, range of motion; modes of manual therapy including: cupping, moxibustion heat therapy, bleeding therapy, magnetic stimulation, the application of topical ointments, liniments and lotions; the prescription of herbal and dietary recommendations; Craniosacral therapy; Massage therapy; exercise advice and healthy lifestyle recommendations.
I understand I have opportunities to discuss with my practitioner the nature and purpose of Acupuncture and Eastern medical procedures, the methods of therapy, the techniques used, and the duration of therapy. Although I am aware that Acupuncture and other procedures used in Eastern medacine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied. I understand that I may seek a second opinion from another health care professional or may terminate therapy at any time.
I understand and am informed that, as in the practice of conventional Western medicine, in the practice of Eastern medicine there are some risks to treatment. I understand that although these risks are unlikely to occur, they are possible. I understand that these risks include, but are not limited to: bruising or pain or other strong sensation where the needle is inserted, or at location where bodywork, cupping (which will can leave marks go away between 1-4 weeks), or topical ointment/ lotion/ liniment is applied, or radiating from those locations; nerve pain, burns, aggravation of current symptoms, appearance of new symptoms and general aches. I do not expect the practitioners to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioners to exercise such judgment during the course of my treatment, as the practitioner feels at the time, based on the facts then known, to be in my best interest.
I understand that Acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment. If there is reasonable cause to believe that treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol, or appears to be overly medicated, then a treatment may not be performed at that time. In this case the patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment.
I understand that Acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when the patient has not eaten properly before the time of treatment, and may result in dizziness, sweating, light headed feeling or other experiences similar to low blood sugar symptoms.
I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment.
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