Chenzen Wellness Centre | Treatment Consent
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of acupuncture on me (or the patient named below for whom I am legally responsible) by the licensed acupuncturist and certified massage therapists at Chenzen Wellness Centre. I understand that the methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Oriental Massage), Oriental herbal medicine, and nutritional counselling. I will immediately notify practitioners of any unanticipated or unpleasant effects associated with the consumption of herbal pills or formulas.
I have been informed that acupuncture is a generally safe method of treatment, but that I may have some side effects, including bruising (especially on the face), numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the licensed acupuncturist uses only sterile single use disposable needles. Burns and/or scarring are a potential risk of cupping and moxibustion. I understand that while this document describes the more common risks of treatment, other side effects may occur. The herbs and nutritional supplements which are from plant, animal, and mineral sources, that have been recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses.
Appointments cancelled or rescheduled more than 24 hours prior to the appointment time are not subject to any additional charges. Appointments cancelled or rescheduled within 24 hours of the appointment time may be charged a Short-notice Cancellation Fee, which will be 50% of the cost for the booked appointment type. If we are able to fill the appointment time from our wait list, the fee will be waived.
I understand some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, rashes and tingling of the tongue. I will notify the practitioner if I become or suspect I have become pregnant.
I do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the licensed acupuncturist to exercise careful judgment during the course of treatment, which the practitioner believes, based on the facts then known is in my best interest. I understand results are not guaranteed. I understand the practitioner may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
I understand that massage therapy is often performed as an adjunct treatment to acupuncture, and may be performed by either the licensed acupuncturist or a certified massage therapist. I understand that massage is basically for the purpose of stress management, relief of muscle tension, and to promote wellness. I also understand that massage therapists do not diagnose mental or physical illnesses nor do they prescribe medication for treatment of disease. Massage works on soft tissue and the therapist may integrate gentle range of motion exercises to the joints but will not administer spinal manipulations.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment; have been told about the risks and benefits of acupuncture and other procedures and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.