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Acupuncture Consent Form

Before undergoing an acupuncture session, it is important that you know and understand some general information including the risks and benefits of acupuncture.

WHAT IS ACUPUNCTURE

Acupuncture is a traditional Chinese medicine technique for balancing the flow of energy life force of the body - called 'chi' or 'qi' energy. This is practiced with the use of needles inserted through a person's skin at specific points of the body called acupuncture points. There are various disorders treated with the use of acupuncture. There is also increased use of this method for treating pain and relief from discomfort.

Other treatments may include acupressure, cupping, electric or magnetic stimulation, scalp acupuncture or moxibustion.

THE ACUPUNCTURE PROCEDURE

The patient shall lie down on a padded table for the treatment. For the insertion of the needles, it shall be inserted through the skin in various depths, depending on the strategic points. These needles are very thin so the patient will not feel pain, but only some mild discomfort. Once it reaches the correct path, the patient might feel some mild aching sensation. The acupuncturist may swirl the needles after placement or apply heat or electrical pulses. The needles will remain in place for around 10 to 30 minutes.

RISKS IN THE PROCEDURE

One may experience soreness or minor bleeding, numbness, tingling, or bruising on the parts where the needles were inserted. We use single-use, disposable needles in our practice so rest assured, risk of infection is down to the lowest minimal if none at all.

There are cases where nausea or drowsiness can occur; this is a good sign of the effects of the procedure. However, if symptoms worsen or continue after 2 days, please notify your acupuncturist. With this, we also do not advise driving after a procedure if you are affected.

Please let us know if you are pregnant or may be pregnant as there are certain acupuncture points that may induce labor which may result in premature delivery or miscarriage.

BENEFITS

Acupuncture has been used effectively for hundreds of years for a variety of diseases. This has also been used for relieving stress, back and joint pains, headaches, eyestrain, it may improve your immune system, relief from allergy, among others.  However, we cannot provide a guarantee for the outcome of any course of the treatment.

ACUPUNCTURE RESTRICTIONS

The risk of complications may happen if one already has a pacemaker. Not everyone is a good candidate for acupuncture. If you have a bleeding disorder or taking some blood thinners, you might have chances of bleeding or bruising. Please check with us and your physician before undergoing acupuncture.

If one has a pacemaker, acupuncture that involves applying mild electrical pulses may not be a suitable method as it may interfere with the pacemaker's operation.

If one is pregnant, certain types of acupuncture may not be suitable given it may stimulate labor and could result in premature delivery. Please notify us if you are pregnant before undergoing the procedure.

HOW DO I PREPARE

In Traditional Chinese Medicine, we use various “tools” for determining what’s going on inside the body. Checking your “pulses” as well as reading your tongue are two diagnostic methods that we use. When you consume coffee or tea beforehand, this can leave a yellow coating on your tongue, which can sometimes be misleading for us when forming a diagnosis (please also refrain from overbrushing your tongue).

 

On another note, consuming a stimulant (like coffee or some teas) prior to your session can increase sympathetic nerve activity (A.K.A: your fight-or-flight response). This works against our goals of helping your body to enter a parasympathetic (or, rest-and-digest) state.

Turn off your cell phone: We’re connected to our cell phones just as much as any person these days, so we understand that the struggle is real when it comes time to setting your phone aside. But we highly encourage you to do so, and to put it on silent (not vibrate), so you don’t get distracted during your treatment. This is your time. Enjoy it.

Arrive with an open heart: Though it’s been practiced for several centuries, acupuncture is still very new for many Westerners. We recommend entering your treatment with an open heart and an open mind.

There may be terms used that are not familiar to you, and we certainly take a different approach to treating the body than you may be used to if you’ve grown up in a Western country, but please feel free to ask questions! We encourage you to stay open to a new perspective, as this mindset also benefits us on a deeper, physiological level; when our minds are more open, our bodies naturally follow suit, leading to more relaxed muscles, vasodilation (which helps to increase circulation), and ultimately, a more productive acupuncture session!

CONSENT STATEMENT

I have read and understood the information provided above. I understand the possible risks of the treatment and its benefits. I have had the opportunity to inquire about details and these were answered to my satisfaction.

I understand that my records may be reviewed by the administration and staff of the clinic, and I understand that these records will remain confidential within the said clinic and will only be released with my written consent.

By providing your initials below, you are voluntarily expressing your consent to the treatment.

Thanks for submitting!

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