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I hereby requested and consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture and traditional Chinese medicine on me (or patient named below, for whom I am legally responsible) by the acupuncture practitioner of Acupuncture & Homeopathy Center named below and /or other licensed acupuncture practitioner serving as back-up for practitioner, whether signatories to this form or not.


I have been informed that acupuncture is generally a safe method of treatment, natural method of healing but, although uncommon, there is some potential risks including minor bruising, numbness or tingling near the sites that may last a few days, dizziness or fainting, a broken needle, or may produce a temporary soreness and flare-up of the symptoms. Larges bruising is a common side effect of cupping. Fainting can most easily be avoided if patient takes care not to come to treatment when he or she is exhausted, tired or hungry. To avoid needle breakage, patient must limit their movements while on the table. With the sterile, disposable needles there is no risk of AIDS or hepatitis from the needles. Unusual risks of acupuncture are rare but include pneumothorax (lung puncture), nerve damage and organ puncture, spontaneous miscarriage. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I understand that the Homeopathy views health and illness in a holistic way and this is different from the standard and conventional approach which usually limits its concerns to individual symptoms. In working with the whole person, the homeopathy regards the mental, emotional, and physical aspects as important, as well. A minor aggravation or worsening of some symptoms may occur as a part of the general healing process.


The acupuncture practitioner must be advised by the patient if he/she has a pacemaker, cardiac condition, bleeding disorder, history of seizures, or may be pregnant. Patient who takes blood thinners a Cummadin (Wafarim) should probably not get acupuncture due to the increase risk of bleeding.


I do not expect the acupuncturist practitioner to be able to anticipate and explain all possible risks and complications of the treatment, and I wish to rely on the practitioner to exercise judgment during the course of treatment, based on the fact that the practitioner knows what is in my best interest. While there a number of alternatives that exist, the prognosis for treatment depend on the patient’s condition, the duration and frequency of treatment and the responsiveness of the patient to both the treatment and the treatment plan. I understand that results are not guaranteed.


Regarding, Group Acupuncture, since more than one person is being treated in the same room at once, it is vital that we work together to respect your privacy and the privacy of others. If you happen to hear someone else’s private information, please keep it to yourself, you would want others to do the same for you.


I understand that the practitioner and / or clinical staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.


By voluntarily signing below, I show that I have read or have had read to me the above consent to treatment. I have been told about the risks and benefits of Acupuncture, Homeopathy, and other procedures, and have had the opportunity to ask questions. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Thanks for submitting!

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