I hereby consent to the performance of acupuncture treatments and other procedures. I understand that methods of treatment may include, but are not limited to, acupuncture, the use of a conventional far infrared and near infrared heat lamp, Cupping, Gua Sha, electrical stimulation, Tui-Na (Chinese massage I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness, or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping and Gua Sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax Infection is another possible risk, although the clinic uses single-use sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of heat lamp use and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I will notify the licensed acupuncturist's who is caring for me if I am or become pregnant. | do not expect the licensed acupuncturist to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the licensed acupuncturist to exercise judgment during the course of treatment which the licensed acupuncturist think at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I understand the licensed acupuncturist and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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.