I hereby request and consent to the performance of acupuncture procedures: I have been informed that acupuncture is a safe method of treatment. Side effects are very unusual, but may including discomfort, pain, dizziness, bruising, or numbness at site of procedure. Unusual and extremely rare risks of acupuncture include nerve damage, organ puncture including lung puncture, infection, and spontaneous miscarriage. Specific Injection Risks: Infection: with standard procedure of sterile needles and antiseptic technique, this risk is very small, but still exists. Redness, heat and swelling are early signs of infection, and should be reported to your practitioner immediately to avoid more serious complications of sepsis (infection in the blood) or osteomyelitis (infection in the bone.) Puncture of nerves, arteries, or veins: This risk varies greatly based on the area of injection. When acupuncture point injections are made in the body of large muscles, this risk is very, very small. In other areas where these structures are larger and/or closer to the surface, the risk is increased. A nerve can rarely be permanently damaged, or bleeding may occur with the puncture of a vein or artery. Puncture of the lung or other vital organ: Injections in the upper chest or back could puncture a lung, and/or a tension pneumothorax can occur. In this condition the lung leaks air into the lung cavity, progressively compressing the lungs and heart. The patient would become very short of breath, which could cause death if left untreated. These side effects are incredibly rare. Allergic reaction to injected substance: Allergic reactions to homeopathic substances have not been reported, and in fact are used to treat allergic conditions. However, local anethetic, vitamins, or other therapeutic substances may cause allergic reaction. A severe lung reaction with anaphylaxis could result in airway constriction possibly leading to death. Our clinic has developed testing protocols to help identify potential allergic reactions, and maintains appropriate products on hand to treat anaphylaxis in the extremely unlikely circumstance that it does occur. I understand that there are no guarantees regarding cure of improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture practitioner or other healthcare provider who may be more qualified or have more specialized training to treat me outside of these facilities. I do not expect the acupuncturist to anticipate and explain all possible risks and complications, and I permit the acupuncturist to determine and/or alter the course of treatment which the acupuncturist judges to be in my best interests based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time. I have read or have had read to me the above consent. In the case of injection therapy, I understand that I will only be injected with substances that fall within the scope of practice of a Licensed Acupuncturist in Colorado. I have also had the opportunity to ask questions about its content, and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for mycondition and for any future condition(s) for which I seek treatment. By signing this form, I agree to accept all risks and release all liabilities from Luke J. Terry, and any associated business.