Consent to Treatment

By signing below, I do herby voluntarily consent to be treated with Acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at VITA Whole Body Care.

 

Acupuncture/Moxibustion:

I understand that acupuncture is preformed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or disease, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effect may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantee concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.

 

Direct Moxibustion:

I understand that if I receive direct moxibustion as part of the therapy, there is a risk of Mild burning or scarring from its use. I understand that I may refuse this therapy.

 

Chinese Herbs:

I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or disease, to modify or prevent pain perception, and to normalize the body’s physiological function. I understand that I am not required to take these substances, but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effects may result form taking these substances. These include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and contact VITA Whole Body Care as soon as possible.

 

Cupping:

I understand that I may be asked to have cupping administered with the treatment. I am aware that certain adverse side effects may result. These may include, but are not limited to: redness, bruising, pain, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.

 

Acupressure/Tui-Na Massage:

I understand that I may also be given acupressure/tui-na massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.

 

I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.

 

Consent to Contact;

VITA Whole Body Care may need to use your name, address, phone number, and your clinical records to contact you regarding appointment, post-appointment care, payment, or other issues related to your care. If this contact is made by phone and you are not at home or work, a message will be left on your voicemail.   VITA Whole Body Care would also ask permission to contact you via email or regular mail for appointment reminders, information that you have asked for specifically (i.e. information about cold flu season, or allergies), research, and birthday cards. VITA Whole Body Care will never release, sell, or rent your private information to any company. We appreciate your understanding.

 
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