Please print and sign the informed
consent form below and bring it with
you to your first session.

Informed Consent for Acupuncture Treatment

I hereby request and consent to the performance of acupuncture treatments and other
Oriental Medicine procedures, including various modes of physiotherapy on me (or the
patient named below, for whom I am legally responsible) by the acupuncturist named
below and/or other licensed acupuncturists who now or in the future treat me while
working or associated with, or serving as a back-up for the acupuncturist named below,
including those working at this or any other office, whether signatories to this form or not.  

I understand that methods of treatment may include, but are not limited to, acupuncture,
moxibustion, Tui-Na (Chinese massage), Chinese Cerbal medicine, and nutritional
counseling.  

I have been informed that acupuncture is a safe method of treatment, but that it may have
side effects, including bruising, numbness or tingling near the needling sites that may last a
few days, and dizziness or fainting.  I understand that I should not make significant
movements while the needles are being inserted, retained, or removed.  I understand that
while this document describes the major risks of treatment other side effects and risks may
occur.

The herbs and nutritional supplements (which are from plant, mineral, and animal sources)
that have been recommended are traditionally considered safe in the practice of Chinese
medicine, although some may be toxic in large doses.  I understand that some herbs may be
inappropriate during pregnancy.  Some possible side effects of taking herbs are nausea,
gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.

I understand that the herbs need to be consumed according to the instructions provided
orally.   I understand that some herbs may have an unpleasant taste or smell.  I will
immediately notify the acupuncturist of any unanticipated or unpleasant effects associated
with the consumption of the herbs.  I will notify the acupuncturist who is caring for me if I
am or become pregnant.

I do not expect the acupuncturist to be able to anticipate and explain all possible risks and
complications of treatment, and I wish to rely on the acupuncturist to exercise judgment
during the course of treatment which the acupuncturist thinks at the time, based upon the
facts then known, is in my best interest.  I understand that results are not guaranteed.

By voluntarily signing below I show that I have read, or have had read to me, this 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.

______________________________________        
Print Name of Acupuncturist

______________________________________
Print Name of Patient                                        

X_____________________________________        
Signature of Acupuncturist

X_____________________________________
Signature of Patient (or Representative)                

X______________________        
Date Consent Completed        

Informed Consent Form