OUTER EAR ACUPUNCTURE – CONSENT FORM
What is periauricular/auricular acupuncture?
Periauricular/auricular acupuncture is a form of therapy in which fine needles are inserted into specific points on the ear(s). Ear Acupuncture involves partially inserting up to five sterile thin needles externally in one or both ears.
Possible Benefits of Treatment
Enter a deeply relaxed state, which is helpful for body detoxification and cravings. In addition, individuals often feel an immediate sense of release and decreased tension and anxiety. Some people experience a greater ability to manage pain symptoms, improved digestion, and greater acceptance, self-awareness, and self-connection.
Side effects are rare:
- Drowsiness. If this occurs, please refrain from driving until you are fully alert.
- Minor bleeding or bruising may occur when the needles are removed (quickly resolved).
- The needles can cause discomfort with or without inflammation. (quickly resolved).
- The symptoms can increase for short periods. The body is detoxing and should resolve in a short time.
- Fainting may occur in a small number of people, particularly at the first treatment.
*These may not preclude participation but
PLEASE INFORM GINA IF:
- you have ever become faint or had a seizure,
- you have a bleeding disorder
- you are taking anticoagulants or any other medication that may increase bleeding,
- you have a damaged heart valve or other cardiac problem, including PACEMAKER
- you have any other particular risk of infection
- you are pregnant
- you have diabetes
Only single-use, sterile, disposable needles are used
Statement of Consent
I confirm that I have read and understood the above information, including potential rare and minor side effects if any. I consent to having periarticular acupuncture treatment. I release Eugenie Ferrara-Bates (DBA Gina Ferrara) and Odonata Reiki Healing Arts LLC of any liability. Parent or Guardian signs for minor.