The Teal Center for Therapeutic Bodywork, Ltd.
Informed Consent for Facial Acupuncture Treatment
Please take the time to read this form, which will provide you with some basic information about acupuncture.
INSTRUCTIONS - This is an informed consent document that has been prepared to help your acupuncturist inform you concerning facial acupuncture treatments, the risks involved, and possible alternatives. Please be advised that this is not a surgical procedure.
It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for facial acupuncture treatments, as proposed by your acupuncturist.
I understand that my treatment may be modified to address: 1) Changes in my condition; 2) changes in my desired results; or 3) changes in the professional standards of acupuncture care. I understand, and agree to adjustments in my treatment as needed to optimally address my well-being, my objectives, and to take advantage of the full range of care options for me.
INTRODUCTION - An acupuncture facial treatment involves the insertion of acupuncture needles into fine lines and wrinkles on the face and neck in order to reduce the visible signs of aging. In Oriental medicine, the meridians or pathways of Qi (energy) flow throughout the entire body from the soles of the feet up to the face and head; consequently, a facial acupuncture treatment addresses the entire body constitutionally, and is not merely “cosmetic.” An acupuncture facial involves the patient in an organic, gradual process that is customized for each individual. It is no way analogous to, or a substitute for, a surgical “face lift”. A treatment session may confine itself solely to facial acupuncture, or it may be used in conjunction with other procedures, including micro-current facial treatment.
POTENTIAL BENEFITS - Facial acupuncture can increase facial tone, decrease puffiness around the eyes, as well as bring more firmness to sagging skin, enhance the radiance of the complexion, and flesh out sunken areas. Customarily, fine wrinkles will disappear, and deeper ones be reduced. As this treatment is not merely confined to the face, but incorporates the entire body and constitutional issues of health. However, I understand that as with all acupuncture care, facial acupuncture treatment involves a gradual, healthful process that is customized for each individual, and that results may vary.
ALTERNATIVE TREATMENT - I understand that other alternatives exist for cosmetic care, including, but not limited to, surgery, such as a surgical facelift, chemical face peels, or liposuction. I realize that there are also risks and potential complications associated with these alternative forms of treatment.
RISKS OF AN ACUPUNCTURE FACIAL TREATMENT - Every procedure involves a certain amount of risk and it is important that you understand the risks involved with an acupuncture facial. An individual’s choice to undergo an acupuncture facial is based upon the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your acupuncturist to make sure you understand the risks, potential complications, and consequences of an acupuncture facial.
• BLEEDING AND BRUISING – As with acupuncture in general, some minor bleeding may occur. This is normal and usually will not leave a bruise. Occasionally, a bruise or a hematoma may appear. With bruising, it is important that you wear
sunscreen when going outside. Topical and internal remedies will be discussed to address bruising. If swelling persists, I understand, I should call my provider immediately.
• INFECTION – Infection at the probe site is very rare after treatment because the probe does not break the skin. If you suspect infection at the probe site (i.e. redness, swelling or warm to the touch), please call me. Additional treatment
or referral to your M.D. may be necessary.
• DAMAGE TO DEEPER STRUCTURES - Deeper structures such as blood vessels, nerves, and muscles are rarely damaged during the course of a facial acupuncture treatment. If this does occur, the injury may be temporary or permanent.
• ASYMMETRY – All facial structures are naturally asymmetrical. Results may vary from side to side due to the natural asymmetry, previous injuries on one side of the body, or severity of symptoms from one side or the other.
• NERVE INJURY - Injuries to the motor or sensory nerves rarely result from facial acupuncture treatments. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to sensory nerves of the face, neck and ear regions may cause temporary or more rarely permanent numbness. Painful nerve scarring is very rare.
• NEEDLE SHOCK - Needle shock is a rare complication after an acupuncture facial.
• UNSATISFACTORY RESULT – There is the possibility of a poor result from a facial acupuncture treatment. You may be disappointed with the results. I understand that I am not having a surgical procedure. The alternatives, risks, and comparisons of surgical procedures versus facial acupuncture treatments have been discussed with me and outlined in this document. Should I have any further questions, I will discuss them with my provider before treatment begins.
• ALLERGIC REACTIONS – In rare cases, local allergies to topical preparations have been reported. Allergic reactions may require additional treatment or discontinuation of treatment.
• DELAYED HEALING – Delayed healing is a rare complication. Smoking and certain health conditions such as diabetes and chronic fatigue syndrome, to name a few, may delay the healing response of any of the aforementioned risks.
• LONG-TERM EFFECTS – Following facial acupuncture treatments, changes in facial appearance may occur as the result of the normal process of aging, weight loss or gain, sun exposure, stress, illness, or other circumstances not related to such treatment. It has been explained that following lifestyle and dietary instructions may enhance the longevity of the results, while non-compliance will adversely affect the longevity of the results from facial acupuncture treatments.
Additional, future treatments may be necessary to maintain the results.
• UNFORESEEABLE IMPACTS – There are many variable conditions, in addition to the risks and potential complications enumerated, that may influence the long-term result from facial acupuncture treatments. While the complications cited are the ones particularly associated with facial acupuncture treatments, this is not an exact science, and other less common complications may arise. Should these or other complications occur, other treatments might be necessary.
UNFORESEEN CONDITIONS – I understand that there are several styles or methods of facial, cosmetic, or rejuvenation acupuncture and have been informed that during the course of facial acupuncture treatments, unforeseen conditions may
necessitate different procedures than those listed above.
HEALTH INSURANCE/FINANCIAL RESPONSIBILITY – I understand that most health insurance does not cover the cost of the facial acupuncture treatments or complications resulting from such treatments. Please contact your insurance if you have any questions about coverage. Depending on whether any or all of the cost of facial acupuncture treatments is covered by an insurance plan, I will be responsible for charges not so covered.
DISCLAIMER - Informed-consent documents are used to communicate information about the proposed procedure along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your acupuncturist may provide you with additional or different information which is based upon all the facts in your particular case and the present state of knowledge within the field of acupuncture. Informed consent documents are not intended to define or serve as the standard of acupuncture. Standards of acupuncture are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the following consent.
AGREEMENT AND CONTINUOUS EFFECT - I have read, or have had read to me, the above consent. It has been explained to me in a way that I understand: a) The risks involved with facial acupuncture treatments; b) That I have alternatives available to me for cosmetic improvements; and c) What protocols will be used in connection with treatment. I have also had an opportunity to ask questions regarding facial acupuncture treatment, and am satisfied that all my questions have been answered. I acknowledgethat no guarantee has been given to me by anyone as to the results that may be obtained. I authorize the release of medical
information, when required. Finally, by signing below I acknowledge that I have been fully informed about, and agree to, facial acupuncture treatments. 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. Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.