It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your practitioner and to make an informed decision about proceeding with treatment.
I consent to the performance of acupuncture and other procedures related to acupuncture, as necessary, including electro-acupuncture by the authorized therapist(s) at Ace Sports Clinic.
The risks associated with acupuncture treatment vary according to each patient’s condition, as well as the location and type of treatment. I understand and am informed that in the practice of acupuncture there are some risks to treatment, including, but not limited to, minor bleeding or bruising, minor pain or soreness, nausea, fainting, infection, shock, convulsions, possible perforation of internal organs, and stuck or bent needles.
I have been advised that only pre-sterilized and packaged needles will be used. All acupuncture needles are properly disposed of after each and every treatment.
I do not expect my therapist(s) to be able to anticipate and explain all possible risks and complications.
I wish to rely on my therapist(s) to exercise judgment during the course of the treatment which based upon the facts then known, is in my best interests. I understand that the results are not guaranteed.
I acknowledge that I have read this consent form and have had an opportunity to ask questions about its content. By signing below I consent to the use of Acupuncture in my treatment. I intend this consent form to cover the entire course of treatment for my present and future conditions for which I seek treatment at Ace Sports Clinic.
You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any feedback or concerns you have to your therapist’s attention. If you are not comfortable, you may stop treatment at any time.
Please be involved in and responsible for your care. Inform your therapist immediately of any change in your condition.
Female Patients: I fully understand that in the case of pregnancy, a risk of causing fetal distress with acupuncture treatment(s) is possible. I hereby state that I am not pregnant, nor is there any possibility that I may be pregnant.