I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible).
I understand the methods of treatment may include, but are not limited to, acupuncture, cupping, electrical stimulation, Tui-Na (Chinese massage), Swedish massage, Chinese herbal medicine, and nutritional and lifestyle counseling.
I have been informed that acupuncture may have some side effects, including occasional bruising. Some bruising may also be a side effect of cupping. This clinic uses sterile one time use disposable needles.
I will notify the acupuncturist who is caring for me if I am or become pregnant, have a change in my condition or medications or have any adverse reactions to treatments.
I understand the clinical and administrative staff may review my patient records, x-rays and lab reports, and that all my records will be kept confidential and will not be released without my written consent.
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.
You have finished the ?Patient Information? form for Passport To Health. Below please enter your name, your email address, and then select the button where the form is to be sent. To the Clinic
To educate, motivate and empower the individual to take charge of their own health. To attain vitality and a strong immune system using, exercise, proper nutrients and healthy lifestyles.