Peony & Tiger Acupuncture (“Company,” “we,” or “us”) respects your right to informed consent regarding acupuncture and Chinese herbal medicine.
This page is designed to inform you of the possible risks of acupuncture and Chinese medicine so that you can make an informed decision to provide your consent for treatment, should you choose to go ahead.
You understand that such procedures may include, but are not limited to, acupuncture, moxibustion, gua sha (dermal friction technique), exercise therapy, Chinese or western herbal medicine, supplements and nutritional counselling.
Acupuncture is a technique utilising fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using compressed and ignited fibre of Artemesia vulgaris, commonly known as Mugwort.
Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment. You are informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. You have been informed that acupuncture may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A haematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. You will immediately notify the acupuncturist if I experience any symptoms or problems.
You understand that you should not make significant movements while the needles are being inserted, manipulated, retained, or removed. You understand that on rare occasions moxibustion therapy may result in a burn at the site of application. You understand that you should not make significant movements while moxibustion is being applied. You will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable.
You are relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. You understand that acupuncture and other Traditional Medicine procedures are not substitutes for treatment by my medical doctor. At any given time throughout the treatment, you may request the practitioner to stop, modify, or change the treatment plan.
This is NOT a waiver form. It is part of our “duty of care” to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections and collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility.
By voluntarily signing the digital intake form, you certify that you have read this page, have been informed of the risks and benefits of acupuncture and traditional medicine, and have had an opportunity to ask questions. You request and consent to acupuncture and traditional medicine care described above. You intend this consent form to cover the acupuncture care for this and future presentations.
PO Box 4274, Baldivis, WA 6171
Email Address: firstname.lastname@example.org
Effective as of 28 January 2020