Cosmetic Facial Rejuvenation Acupuncture Consent Form printable pdf download

Cosmetic Facial Rejuvenation Acupuncture Consent Form

10815 Bathurst St.

Richmond Hill, ON L4C 9Y2

Tel.: 905-737-5559 Fax: 905-737-5556

Cosmetic Facial Rejuvenation Acupuncture

Consent Form

I, ______________________ understand that acupuncture, and other modalities of Chinese Medicine (including

acupressure, massage, herbs, aromatherapy, cupping, and electrical stimulation), may cause minor discomfort, and

may irritate the skin or leave a mark or bruise.

I understand that no claims, promises, or guarantees are being made, and I accept full responsibility for the risk and

effectiveness of all treatment.

I, ________________________ have not had any cosmetic surgery or botox/filler injections in the last 6 months and

do not have any of the following contraindicated conditions:

Uncontrolled high blood pressure, regular migraines, diabetes, cancer, hepatitis, AIDS, haemophilia, a pituitary

disorder such as a tumor, acute cold/flu, herpes outbreak, pregnancy, intoxication or hangover from alcohol or other

drugs.

Please indicate if you have had any cosmetic surgeries in the past:

___________________

_____________________

Patient Printed Name

Date

___________________

_____________________

Patient Signature

Date

info@HappyFamilyWellness.ca

Cosmetic Facial Rejuvenation Acupuncture Consent Form