Consent Form

ACUPUNCTURE INFORMED CONSENT TO TREAT

I hereby consent to 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) by acupuncturists Joyce Nemser and Michelle Racine.

Methods of treatment may include acupuncture, moxibustion, cupping, gua sha, electroacupuncture or nutritional counseling based on the concepts of traditional Chinese medicine.

I understand that acupuncture is a generally safe method of treatment, but that it may occasionally have some side effects, including bruising, numbness, tingling or pain near the needling site that may last a few days, and in rare cases, dizziness or fainting.

Bruising is a common side effect of cupping and gua sha.

Acupuncture treatment is not a replacement for diagnostic medical procedures. An acupuncturist does not diagnose according to standard medical practice, nor should a “Chinese Diagnosis” be considered a replacement for standard medical evaluation or testing. If you have any concerns about what may be causing your symptoms, you must see a medical doctor.

Signature__________________________________

Date_____________________________________

Download this Form JoyCommunity_Consent_Apr2017

TIPS FOR 1st TIMERS

• Please keep shoes on when walking around the clinic
• Put belongings in wicker basket by your chair
• Once in your chair take off socks & shoes, roll your pant-legs up to your knees and sleeves up to your elbows
• We have earplugs available, just ask
• No scented products/ perfume on the days you are here, thanks!

The soothing atmosphere exists in a community clinic because all of the patients create it by relaxing together. Maintaining this reservoir of calm requires that no one talk much in the clinic space and that when we do, we talk in a whisper.

Enjoy your treatment, we’re glad you’re here!