Acupuncture Information and Consent Form
What is Acupuncture and how is it defined by New York State?
“Profession of acupuncture” is the treating, by means of mechanical, thermal, or electrical stimulation affected by the insertion of needles or by the application of heat, pressure, or electrical stimulation at a point or combination of points on the surface of the body predetermined on the basis of the theory of the physiological interrelationship of the body organs with an associations point or combination or points for diseases, disorders, and dysfunctions of the body for the purpose of achieving a therapeutic or prophylactic effect.
When would I use the services of a New York acupuncturist?
Many conditions may respond to acupuncture, including those related to the following:
Neurological system, Musculo-skeletal system, respiratory system, gynecologic and reproductive system, digestive system, and genito-urinary system. Acupuncture may also help with acute and chronic pain, maintaining emotional balance, stress reduction, and detoxification.
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working, or associated with, or serving as a back-up for Circle Wellness. within this office or clinic, or any other office or clinic associated with the practice, whether signatories to this form or not.
I understand methods of the treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), and nutritional counseling. I have been informed that acupuncture is a generally safe method of treatment but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting may occur. Burns and/or scarring are a potential risk factor of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, organ damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.
I understand that while this document describes the major risks of treatment, other risks and side effects may occur. I will notify a clinical staff member who is caring for me if I am or become pregnant. I do not expect the clinical staff to be able to anticipate and explain all potential risks of complications of treatment, and I wish to rely on the clinical staff to exercise judgement, to be in my best interest. I understand that results are not guaranteed.
I understand that the clinical and administrative staff may review my patient records, but all records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, and understand the above consent to treatment, benefits and potential risks of acupuncture or other procedures, and have had an opportunity to ask questions and voice concerns. I intend this consent form to cover the entire course of my treatment for my present condition and for any future condition(s) for which I seek treatment.
What is the relationship between an acupuncturist and a medical doctor?
Each licensed acupuncturist shall advise each patient as to the importance of consulting with a licensed physician regarding the patient’s condition and shall keep on file with the patient’s records, a form attesting to the patient’s notice of such advice. Such form shall be in duplicate, one copy retained by the patient, signed, and dated by both parties, and they shall be prescribed in the following manner:
I confirm that I have read and understand the above information and I consent to acupuncture treatment. I understand that at any time I can refuse acupuncture treatment.
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