Doctors Of Chiropractic Services - Brantford DOCS



Patient Informed Consent for Acupuncture TreatmentI hereby request and consent to the performance of acupuncture treatments, including various modes of physiotherapy on me (or the patient named below, for whom I am legally responsible) by the doctors of this chiropractic clinic, and/or other licensed doctors of chiropractic who now or in the future work here. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping & gua sha, electrical stimulation, breathing techniques, exercise therapy, and nutritional counseling. I have been informed that acupuncture is a safe method of treatment, but it may have side effects and risks. In particular:Bruising, numbness or tingling near the needling sites that may last a few days and dizziness or fainting. Spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection although the acupuncturist below uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment other side effects and risks may occur. I understand that I should not make significant movements while the needles are being inserted, retained, or removed.I will notify the doctor who is caring for me if I am or become pregnant.I do not expect all possible risks and complications of my treatment to be anticipated and explained, and I wish to rely on the doctor to exercise judgment during the course of treatment and I understand that results are not guaranteed.I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of acupuncture treatments, the treatment options and recommendations for my condition, and the contents of this consent. I intend this consent to apply to all my present and future acupuncture treatments. Dated this ________________ Today’s Date_______________________________ __ _________________________________ Patient Signature (Legal Guardian) Witness Signature Name: __________________________ Name: ______________________________ Patient Name (please print) Witness Name (please print) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download