Patient Information Consent Form For Chinese Medicine
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2Patient Information & Consent Form for Treatment with Chinese Medicine
What is acupuncture?
Acupuncture is a form of therapy in which fine, single-use, sterile, disposable needles are inserted into specific points on
the body to treat health imbalances, alleviate pain and restore the body’s normal physiological functions.
Is acupuncture safe?
Acupuncture is very safe. Serious side effects are rare—less than one per 10,000 treatments.
Does acupuncture have side effects?
Listed below are possible adverse side effects which include but are not limited to the following:
~Drowsiness (occurs in a small number of patients and if affected, you are advised not to drive)
~Minor bleeding or bruising (occurs after acupuncture in about 3% of treatments)
~Pain during or after treatment (occurs in about 1% of treatments)
~Fainting (particularly at the first treatment)
~Organ puncture (very rare especially with proper technique)
~Symptoms getting worse after treatment (less than 3% of patients); you should tell your
acupuncturist about this—it can also be a natural part of the healing process.
What is moxibustion and its risks?
Moxibustion is the application of heat to the skin at certain points on or near the surface of the body using packed herbs.
There is a risk of burning or scarring from the treatment which is rare.
What is cupping/Gua Sha and its side effects?
Cupping involves a localized suction produced by briefly heating a small glass cup. Gua Sha is performed by using a
smooth-edged instrument to scrape the skin over the affected area. Cupping or Gua Sha may result in reddish/purplish
marks in the area treated (that can resemble bruising) which typically resolve in 3-7 days.
What are the side effects of acupressure/shiatsu massage?
Acupressure or shiatsu is the application of pressure to parts of the body with the intention of relaxing the muscles and
stimulating acupuncture points. Some side effects include but are not limited to: bruising, sore muscles or aches, and the
possible aggravation of symptoms existing prior to treatment.
What are the benefits and risk of Chinese herbal formulas?
Your practitioner may use Chinese herbal formulas in the form of teas, powders or tablets to support your body and clear
away imbalances. It is possible that if the formula doesn’t agree with you, the herbs may cause allergic reactions,
stomach upset or other adverse effects in which case you should stop taking them and let your practitioner know so she
can adjust the formula. Your practitioner may also give you dietary advice from a Chinese medicine perspective and
again if you notice any adverse effects, communicate with your practitioner because it may reveal important information
about the state of your health and digestion.
Is there anything your practitioner needs to know?
Apart from the usual medical details, it is important that you let your practitioner know:
~if you have ever experienced a fit, faint or funny turn
~if you have a pacemaker or any other electrical implants
~if you have a bleeding disorder
~if you are taking anti-coagulants or any other medication
~if you have damaged heart valves or have any other particular risk of infection
~if you are currently or possibly pregnant or a breast feeding mother
Statement of Consent
I have carefully read and understand all of the above information.
I understand that I may ask my practitioner for a more detailed explanation.
I understand that regular primary care by a licensed physician is strongly recommended.
I consent to treatment while under the care of Dr. Vanda Huang and understand that I am free to refuse/stop treatment
and/or seek alternative treatment at any time. I will communicate any concerns or questions.
Printed Name: _________________________________________________
Signature:_____________________________________Date:____________
~please turn this page over~
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