Phw Acupuncture Intake Form (Page 4 of 4) in pdf

Acupuncture Information and Informed Consent

Voluntary

I hereby voluntarily consent to be treated with acupuncture by Delaware Licensed Acupuncturists at

Partners in Health and Wellbeing. I understand that I may be treated with the application of insertion of

sterile acupuncture needles and/or finger pressure and/or the application of heat to the skin and/or

cupping/gua sha and/or Chinese dietary therapy.

I understand that the practice of Acupuncture and Oriental medicine is not an exact science and there

are no guarantees that have been made to me as a result of treatment.

Possible Side Effects/ Healing Response

I understand that the treatment my result in certain side effects including local bruising, temporary pain

or discomfort at insertion site, slight bleeding, or fainting. Conventional medical therapy may also be

indicated, either in response to an emergency or as deemed necessary in the discretion of a licensed

physician.

Medical Referral

I understand that if there is a worsening of my ailment or condition, or if it does not improve within the

time estimated by my practitioner, or if a new ailment or condition arises, that I should consult a licensed

physician. If you request that the Partners in Health and Wellbeing clinicians discuss your case with

another healthcare provider we will gladly do so provided that you have signed a medical release

form. This is a professional standard among all licensed healthcare providers.

Infectious Disease/ Clean Needle Procedure

I understand that infectious organisms can be carried through the air, through physical contact, and

through body fluids. I understand that my acupuncture practitioner uses Universal Precautions to guard

against the spread of infection. I understand that Partners in Health and Wellbeing follows strict clean

needle procedures. Only sterile, single-use disposable acupuncture needles are used and are

discarded in a biohazard container.

Patient Responsibility

I understand that it is my responsibility as a patient to inform the acupuncture practitioners at Partners in

Health and Wellbeing about all aspects of my health and that as treatment progresses, to inform my

practitioner of any changes that occur. I have carefully read and understand the above information. I

am aware of what I am signing and have felt free to ask questions.

____________________________________________________________________________________________________

Patient’s Printed Name: ________________________________________

Patient’s Signature: _____________________________________________

Date: ___________________

Witness Signature: ______________________________________________

Date: ___________________

CONSENT TO TREAT A MINOR CHILD

I authorize Partners in Health and Wellbeing to administer Acupuncture and Oriental Medicine as

deemed necessary to ______________________________________who is my

_____________________________________ (relationship).

Adult’s Signature: _______________________________________________

Date: ___________________

Witness Signature: _______________________________________________

Date: ___________________

Phw Acupuncture Intake Form Page 4