Acupuncture Intake Form - Redefined Health (Page 3 of 3) in pdf

Acupuncture Intake Form - Redefined Health Page 3

CONSENT TO TREATMENT

I do hereby voluntarily consent to be treated with acupuncture, herbal therapy, cupping, electro-acupuncture and guasha

administered at Redefined Health, 10118 124 Street NW, Edmonton, AB.

I understand that acupuncture is performed by the insertion of needles through the skin, and/or by the application of heat

to the skin, at certain point on or near the surface of the body. Acupuncture attempts to restore normal physiological body

functions, modify or prevent pain perception.

I have been made aware that certain adverse side effects may result. These could include, but are not limited to, some local

bruising, minor bleeding, fainting, temporary pain or discomfort, and possibly temporary aggravation of symptoms.

I understand that acupuncture has been safely practiced for centuries. I also understand that no guarantees concerning its

use and effects are given to me and that I am free to discontinue treatment at any time.

I have carefully read and understand all of the foregoing and I am fully aware of what I am signing.

Patient Name

Patient Signature

Date

Parent/Guardian Name

Parent/Guardian Signature

Date

Witness Name

Witness Signature

Date

Acupuncture Intake Form - Redefined Health Page 3