Acupuncture is performed by the insertion of per-sterilized, disposable needles through the skin, and or the application of heat or electrical simulation to the skin, at certain points on the body.  Chinese herbs  may be recommended for internal or external use. Although rare, certain side effects may result from  acupuncture or the use of herbs. Please read the following statements about the types of treatment offered at this clinic and their potential risks. Your practitioner will explain the treatment that is planned for your condition and answer any questions you have about it.

Procedures and products that may apply to my treatment: Acupuncture needles, gua sha, moxibustion, massage, cupping, herbs, and acupressure.

 

Potential risks and side effects of acupuncture and Oriental medical procedures may include: Minor bruising, possible pain at the site of insertions and needle sickness (for those with extreme sensitivity to needles).

~  I understand the treatment modalities that may be applied in this clinic, and have been informed of the potential risks of said treatment.

 

Payment for service  ~ I understand that I am responsible for payment of services.

 

Usage of Personal Health Information (PHI)

~  I understand that individually identifiable information about me such as name, address, birthdate and diagnosis can be used by authorized staff of this clinic for the purposes of treatment, payment and healthcare operations.
~  I understand that I must give specific consent (usually in written form) before any of my PHI can be released to any person or entity outside this clinic, with the exception of PHI which is used to bill my insurance companies.
~  I understand that minimally necessary PHI may be released for  worker’s compensation purposes, or in special situations such as public health activities, in compliance with Australian Federal, State  or Local  laws.

 

 

 

Patient’s signature: …………………………………………………………………………    Date:  …………………………………………….

 

Consent to treat a child

~  I authorize Ariel Acupuncture Services to administer acupuncture care as deemed necessary to my ………………….    (relationship).

 
Patient’s name:  …………………………………………………….

 

 

Adult’s signature: …………………………………………………………………………    Date:  …………………………………………….