Informed Consent For Acupuncture / Chinese Medicine Services
Acupuncture / Chinese Medicine Services
You acknowledge that you voluntarily request and consent to the performance of acupuncture treatments and other Chinese medicine procedures (collectively, the “Services”) offered by the Center and performed by a licensed acupuncturist employed by, working for, or associated with the Center. You understand that Services may include, but are not limited to, diagnostic techniques such as questioning, pulse evaluation, palpation on a variety of areas of my body, observation, range of motion, muscle, etc.; modes of manual or physical therapy such as Asian body work, acupressure, insertion and manipulation of acupuncture needles, administration of thermal or electrical treatments, moxibustion; energy flow exercise; suggestion of herbal as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle counseling.
Our Services are not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.
The Center offers opportunities for you to discuss the nature and purpose of our Services with our licensed acupuncturists, including via a complimentary online consultation that you can schedule prior to your in-person appointment. Although acupuncture and the other procedures used in Chinese Medicine have helped millions of people, you understand that no guarantee of cure or improvement in your condition is given or implied.
You understand and acknowledge that, as in the practice of conventional Western medicine, in the practice of Chinese Medicine there are some risks of treatment. Although these risks are unlikely to occur, they are possible. You understand that these risks include, but are not limited to: bleeding, bruising, puncture of organs, pain or other strong sensation at the location of where a needle is inserted or radiating from that location, nerve pain, burns, blisters, aggravation of current symptoms, appearance of new symptoms, general aches, fatigue, dark red or purple marks from cupping, skin itching, redness, discomforts from taking herbs, sprains, strains, dislocation, miscarriage, disc injuries, and strokes. Infection is another possible risk, although the Center uses sterile disposable needles and maintains a clean and safe environment.
You acknowledge that you cannot expect our licensed acupuncturists to be able to anticipate and explain all risks and complications, and you wish to rely on the acupuncturists to exercise such judgment, during your treatment, as the acupuncturists feels at the time, based on the facts known, to be in your best interest. You understand that you must inform, and continue to fully inform, the Center and our licensed acupuncturists of any medical history, family history, medications, and/or supplements being taken currently (prescription and over the counter).
You understand and acknowledge that acupuncture and Chinese medicine treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment. If there is reasonable cause to believe that the treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol or appears to be overly medicated, then a treatment may not be performed at that time. The patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment.
You knowingly, voluntarily, irrevocably, and expressly release and waive any claim you may have against the Center, for any injury or damages that you may sustain as a result of the performance of the Services on you. You hereby release and forever discharge the Center from any liability whatsoever out of or in connection with the performance of the Services on you and will further indemnify and hold us harmless from any loss, cost, damage, or expense (including attorney’s fees and cost of litigation) that we may incur in defending any claim made by you or anyone making a claim on your behalf, even if the claim is alleged to or did result from negligence.
Appointment Scheduling and Payment Policy
You may schedule Services on our website www.reconnecthealth.com or directly via a provided scheduling link. All Services require online registration with a valid credit card and payment at the time of service. Please provide a 24-hour advance cancellation or reschedule notice otherwise you will be charged for the missed appointment.
All personal information you share with the Center will be kept strictly confidential unless you consent to sharing it or unless mandated by law. However, if you elect to communicate with the Center by email or cellular text message (SMS), please be aware that email and text messages are not secure, and confidentiality cannot be assured.
A parent or legal guardian’s authorization is required if the patient is under the age of 18. As a parent or legal guardian of your minor child, you consent to the above terms and conditions in consideration of the performance of the Services on your minor child.