Informed Consent for Acupuncture & Chinese Medicine Treatment
I (the client or representative legally responsible) hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures on me, by the acupuncturist of Yuan Qi Acupuncture and Health Center (KvK: 74566636 / AGB-code: 90066142).
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, Gua Sha, electrical stimulation, breathing techniques, Qi Gong (exercise therapy), Tui-Na (Chinese massage), Chinese herbal supplements, nutritional counseling, etc.
I am aware that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites, that may last a few days, and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Bruising is a common side effect of cupping and Gua Sha.
I am aware that unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion or cupping. I understand that while this document describes the major risks of treatment other side effects and risks may also occur.
I am aware that the herbs and nutritional supplements (which are from plant, mineral, and animal sources) that have been recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.
I understand that the herbs need to be consumed according to the instructions provided orally and in writing. I understand that some herbs may have an unpleasant taste or smell. I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs.
I will notify the acupuncturist who is caring for me if I am or become pregnant.
I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications related to the treatment. I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.
By voluntarily booking an appointment at Yuan Qi Acupuncture and Health Center, and clicking the checkbox on the booking form, I show that I have read, or have had read to me, this consent to treatment, have been informed about the risks and benefits of acupuncture and other procedures, and that I conscientiously accept everything mentioned within this consent form. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.