Consent for Acupuncture
Please read this information carefully, and ask your practitioner if there is anything that you do not understand.
I, (Patient's First Name Patient's Last Name) give my voluntary consent for the administration of medical acupuncture and other ancillary techniques as deemed appropriate by my treating therapist.
Acupuncture has been explained to me as a therapeutic treatment performed by the insertion of SINGLE USE, PRE-PACKAGED, PRE-STERILIZED, UNEXPIRED NEEDLES AND DISPOSABLE NEEDLES ARE ONLY USED FOR EACH ACUPUNCTURE TREATMENT.
The needles are inserted through the skin, into the underlying muscles and tissues at specific points on the body for the purpose of alleviating pain, relieving pressure/irritation of nerves, improving mobility and re-establishing normal function.
Ancillary techniques of acupuncture may include one or more of the following:
Does acupuncture have side effects?
Acupuncture is generally very safe. Serious side effects are very rare-less than one per 10,000 treatments.
Some side effects you need to be aware of are;
Apart from the usual medical details, it is important that you let your practitioner know and I will immediately notify the practitioner of any changes:
I do not expect the acupuncture practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the therapist, to exercise proper judgment during the course of the treatment to make decisions based upon my best interest.
I accept the fact there is no guarantee of the effectiveness of the treatment.
I understand that in the event of a suspected pneumothorax I am to go DIRECTLY TO THE HOSPITAL and instruct them that I have had acupuncture and that I suspect that I have a pneumothorax. I also may wish to call my therapist and inform them of the event.
I am aware that I may withdraw this consent and discontinue treatment at any time.
I hereby certify that I have read the above information and have had my questions answered to my satisfaction.
I, (Patient's First Name Patient's Last Name) give my voluntary consent for the administration of medical acupuncture and other ancillary techniques as deemed appropriate by my treating therapist.
Acupuncture has been explained to me as a therapeutic treatment performed by the insertion of SINGLE USE, PRE-PACKAGED, PRE-STERILIZED, UNEXPIRED NEEDLES AND DISPOSABLE NEEDLES ARE ONLY USED FOR EACH ACUPUNCTURE TREATMENT.
The needles are inserted through the skin, into the underlying muscles and tissues at specific points on the body for the purpose of alleviating pain, relieving pressure/irritation of nerves, improving mobility and re-establishing normal function.
Ancillary techniques of acupuncture may include one or more of the following:
- Electro-acupuncture- where the needles are electrically stimulated at various frequencies to increase the therapeutic benefit.
- Dry needling- where muscles are briefly needled by an acupuncture needle, held in a needle holder, to release trigger points and spasms.
Does acupuncture have side effects?
Acupuncture is generally very safe. Serious side effects are very rare-less than one per 10,000 treatments.
Some side effects you need to be aware of are;
- Drowsiness occurs after treatment in a small number of patients, and if affected, you are advised not to drive.
- Minor bleeding or bruising occurs in about 1% of treatments.
- Existing symptoms can get worse after treatment (less than 3% of patients). You should tell you acupuncturist about this, but it is usually a good sign.
- Fainting can occur in certain patients, particularly at the first treatment.
- Pneumothorax the presence of air or gas in the cavity between the lungs and the chest wall, possibly causing the collapse of the lung. Symptoms may include: chest pain that usually has a sudden onset. The pain is sharp and may lead to feelings of tightness in the chest, shortness of breath, rapid heart rate, rapid breathing, cough or fatigue.
- In addition, if there are particular risks that apply in your case, your practitioner will discuss these with you.
Apart from the usual medical details, it is important that you let your practitioner know and I will immediately notify the practitioner of any changes:
- If you have ever experienced a fit, faint or funny turn while on the table or getting off the table.
- If you have a pacemaker or any other electrical implants.
- If you have a bleeding disorder.
- If you are taking anti-coagulants or any other medications.
- If you have damaged heart valves or have any other particular risk of infection.
- If you are pregnant- a risk of causing fetal distress with acupuncture treatment(s) is possible.
I do not expect the acupuncture practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the therapist, to exercise proper judgment during the course of the treatment to make decisions based upon my best interest.
I accept the fact there is no guarantee of the effectiveness of the treatment.
I understand that in the event of a suspected pneumothorax I am to go DIRECTLY TO THE HOSPITAL and instruct them that I have had acupuncture and that I suspect that I have a pneumothorax. I also may wish to call my therapist and inform them of the event.
I am aware that I may withdraw this consent and discontinue treatment at any time.
I hereby certify that I have read the above information and have had my questions answered to my satisfaction.
