Welcome To Qiworks Community Acupuncture Page 3
ADVERTISEMENT
1
2
3
4PATIENT INFORMATION AND CONSENT FORM
Is acupuncture safe?
Acupuncture is generally very safe.
Serious side effects are exceedingly rare.
QiWorks uses only sterile, disposable, single-use needles and maintains a clean and safe environment.
Does acupuncture have side effects?
Like all medical treatments, acupuncture can cause side effects, including but not limited to the following:
Slight pain, numbness, bleeding, bruising, and/or tingling at the insertion site that may last a few days.
o
Symptoms worsening after treatment. If this occurs, you should tell your acupuncturist. Usually it is a
o
natural part of the healing process before improvement begins.
The following side effects are extremely rare; notify us immediately of any occurrence.
o Dizziness or fainting during or immediately after a treatment. To help avoid this, please do not receive
acupuncture on an empty stomach or on an overly full stomach.
o Rashes caused by the alcohol used to clean the skin or due to a reaction to the needle itself.
o Infection.
o Nerve injury (due to accidental nerve puncture).
o Spontaneous miscarriage.
o Perforation of vital organs.
o Needle breaking while inserted in the body.
o Other side effects or risks may occur.
Side effects of herbal and homeopathic remedies include nausea, gas, stomachache, headache, vomiting,
diarrhea, rashes, hives, tingling of tongue, and dizziness. Some may be inappropriate during pregnancy.
Is there anything your practitioner needs to know?
Apart from the usual medical details, it is important to let your practitioner know if you have had:
o Fainting or seizures.
o A pacemaker or other electrical implants.
o A bleeding disorder.
o Anti-coagulant medication (such as Coumadin or Warfarin).
o Diabetes, a compromised immune system, or any other particular risk for infection.
o If you may be pregnant or plan to become pregnant during the course of treatment.
Statement of Consent:
I confirm that I have carefully read and understand all of the above information and am fully aware of what I
am signing. I understand that QiWorks Community Acupuncture, LLC (“QiWorks”) does not provide primary
care, or Western (allopathic) medical care. I hereby release QiWorks and its employees and subcontractors
from any and all liability that may occur in connection with the acupuncture treatment I receive, except for
failure to perform with appropriate medical care. I hereby give my consent to acupuncture and any herbal/
homeopathic treatment for my present condition and for any future condition(s) for which I seek treatment.
Signature of Patient (or Parent/Guardian):________________________________________________________
Printed Name:________________________________________________ Date: _________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business