Collier Acupuncture

Informed Consent to Acupuncture Treatment

Consent for Treatment

New patients must take the time to read about treatments and their effects on the body.

I voluntarily consent to receive acupuncture and related therapies provided by Collier Acupuncture. I understand that treatments may include, but are not limited to:

• Acupuncture

• Auricular (ear acupuncture)

• Electro-acupuncture

• Cupping therapy

• Gua Sha

• Moxibustion (heat therapy)

• Chinese herbal recommendations (if applicable)

• Sound healing

• Flower essences

• Energy balancing techniques

Benefits

I understand that the purpose of treatment is to promote health and well-being. Potential benefits may include pain relief, improved physical function, stress reduction, relaxation, and support for overall health. No guarantees have been made regarding the outcome of treatment.

Risks

I understand that acupuncture is generally considered a safe procedure when performed by a licensed practitioner; however, possible side effects and risks may include:

• Temporary soreness or bruising

• Minor bleeding at needle sites

• Dizziness or lightheadedness

• Fatigue

• Temporary worsening of symptoms

• Skin irritation from cupping or moxibustion

• Rare risks including infection, fainting, or injury despite appropriate precautions

Herbal Products and Supplements

If Chinese herbs, flower essences, or nutritional supplements are recommended, I understand they are intended to support my health but are not guaranteed to cure disease. I agree to inform my practitioner of all medications, allergies, and medical conditions.

Medical Care

I understand that acupuncture is not a substitute for medical diagnosis or treatment by a physician. I have been advised to seek appropriate medical care for serious or emergency conditions and to continue taking prescribed medications unless instructed otherwise by my medical provider.

Pregnancy

If I am pregnant, attempting to become pregnant, or believe I may be pregnant, I will inform my acupuncturist before treatment.

Right to Refuse

I understand that I may ask questions at any time and may refuse or discontinue treatment at any point.

Consent

I have read (or had read to me) the information above. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I voluntarily consent to receive acupuncture and related therapies from Collier Acupuncture.

Include your personal information below.

If patient is a minor:

Patients who are younger than 18 years old are considered a minor. If this applies to you, a parent/guardian is required to provide their information and signature. Parents/guardians should understand the effects treatment has on the body.