New Patient Intake Form (Page 3 of 3) in pdf

Consent to Treatment

, hereby consent to acupuncture and/or other

techniques used in the practice of Traditional Chinese Medicine provided to me for the relief of presenting symp-

toms, improved health and well-being, reduced stress and general relaxation.

Side Effects: While acupuncture is a very safe natural method of treatment, certain side effects may result. These

could include, but are not limited to, local bleeding and/or bruising, temporary pain or discomfort, numbness or

tingling near the needle site that may last a few days, dizziness or fainting, temporary aggravation of symptoms, and

in very rare cases internal organ perforation. Good communication is key to receiving a treatment that keeps you

safe and is within your comfort zone. Please let the practitioner know if you are uncomfortable.

Responsibility: Acupuncture is a valuable complement to Western medicine, but, is not a substitute for it. While we

can provide care for many health issues, you should visit your primary care physician for regular check-ups or the

hospital for emergencies and potentially serious health conditions.

Pregnancy: Acupuncture can be very beneficial in improving fertility, treating any symptoms during pregnancy, and

assisting in the birthing process and postpartum care. Please notify the acupuncturist if you are trying to conceive or

have become pregnant so they can make necessary adjustments to your treatment plan.

Privacy: Sharing important details of your health history is helpful in determining the best treatment plan for you.

Personal records will be viewed and discussed by acupuncturists at Red River Acupuncture, but, will otherwise be

kept confidential. No information will be released without consent. Please notify the acupuncturist if there are

certain topics that need extra discretion.

Cancellation policy: Since scheduling an appointment involves the reservation of time specifically for you, we ask

that you notify us if you need to cancel or reschedule an appointment. You may cancel your appointments online up

to 24 hours prior to treatment. After that please call the clinic. Sessions missed without advance notification will

result in a cancellation fee equal to the cost of treatment.

I have carefully read and understand all of the above.

Signature:

Date:

New Patient Intake Form Page 3