Acupuncture Consent Form

Informed Consent for Acupuncture Treatments at Lavender on the Hill

Please read carefully this carefully and speak to Therapist if you have any questions.

Acupuncture & Dry Needling

Acupuncture and Dry Needling are treatment techniques in which fine, sterile needles are inserted into specific parts of the body to produce a therapeutic effect - such as pain relief or improved muscle function. In general Acupuncture may make patients feel slightly drowsy/relaxed. This can occur during the session for the strong reactors, or later the same day. Some people may not experience it at all. This does not mean that Acupuncture won’t work.

Anything we need to be aware of

Are you pregnant or trying to be pregnant?

Have you ever experienced seizure?

Do you have pacemaker or unstable heart condition?

Are you on anti-coagulants or medications?

Do you have any blood disorders such as Hemophilia, HIV, Hepatitis?

None of the above

Statement of Consent

I have read the above consent form. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above mentioned Acupuncture or Dry-Needling procedures. I intend this consent form to cover the entire course of treatment for my present and future conditions for which I seek treatment. I am aware that I can refuse treatment at any time.

Signed (Print name):

Date

Acupuncture Consent Form

Lavender on The Hill Locations