Please take some time to read through this Informed Consent now, so you don’t feel rushed when you come for your appointment. If you are satisfied, you can sign one when you attend your first session.
This is not a waiver form. It is part of my duty of care to you that I inform you of any pertinent risks associated with professional treatment techniques, so that you may give informed consent. Please read this carefully.
I hereby request and consent to the performance by the practitioner named above, on me (or on the client named below, for whom I am legally responsible) of acupuncture treatments and other Traditional Chinese Medicine (TCM) procedures. I understand that methods of treatment may include, but are not limited to: acupuncture, Shiatsu (Japanese bodywork/massage), Chinese Herbal Medicine, electro-acupuncture, moxibustion, cupping, Gua Sha (‘spooning’), dietary and exercise/stretching suggestions.
I have been informed that acupuncture has the effect of harmonising physiological functions, of being applied across a wide range of dysfunctions and conditions, and is generally a very safe method of treatment. Serious side effects are very rare, – less than 1 per 10,000 treatments. I understand that there may be some slight bruising and tingling around the needling sites, that can last up to a few days. I understand that existing symptoms can occasionally get worse after treatment and that fainting can occur in certain clients, particularly at the first treatment. I understand that there may be some superficial, temporary marking and/or bruising after cupping or Gua Sha.
I understand that some acupuncture points or techniques may be inappropriate during pregnancy, and I will notify the practitioner if I am pregnant or think I may be. I understand that there have been extremely rare instances of more serious complications, such as spontaneous miscarriage, nerve damage and organ puncture, including collapsed lung (pneumothorax). I understand that infection is a potential risk, and that this acupuncture practice uses only individually sterile-packed, single-use disposable needles and maintains a clean and safe environment. I understand that superficial burns are a potential risk of moxibustion. I understand that I may need to remove or loosen some items of clothing for some treatment procedures.
I understand that the herbs may need to be prepared and the preparations consumed or used according to instructions provided orally and in writing. The herbs may have an unpleasant smell and/or taste. I understand that the herbs are traditionally considered safe when properly used in the practice of Chinese Medicine, although some may be toxic if taken in large doses. I understand there could be potential interactions between the herbs and some medications, and I will inform the practitioner of all medications and supplements I am taking. I understand that some herbs may be inappropriate during pregnancy, and I will notify the practitioner if I am pregnant or think I may be. Some possible side effects of Chinese Herbs include: nausea, gas, abdominal pain, vomiting, headache, diarrhoea, rashes, and tingling of the tongue. I will immediately inform the practitioner of any unanticipated or unpleasant effects associated with the consumption or use of the herbs.
I do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the practitioner to exercise judgement, during the course of treatment, which the practitioner thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.
I understand that all my records will be kept confidential, and will not be released without my written consent.
I understand and agree that I am to give a minimum of twelve hours notice for cancellation or rescheduling of appointments, and that failing this I will be charged the full fee. I understand that if the practitioner cancels or fails to honour my appointment with less than twelve hours notice, my next appointment will be free of charge.
By voluntarily signing below, I attest that I have read, or have had read to me, the above consent to treatment, that I have been told about the risks and benefits of acupuncture and other procedures used at this practice, and have had the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition, and for any future conditions for which I seek treatment.
If signing for client, please specify relationship.
Client signature (or client representative) Date