I, or the person listed below, have discussed with my Traditional Chinese Medicine or Acupuncturist the specifics of my assessment or treatment and understand nature, risks and reasons for this procedure. I voluntarily consent to Traditional Chinese Medicine/Acupuncture and understand that I may withdraw my consent and halt my participation at any time.

1. I understand that some of the techniques used under the scope of Traditional Chinese Medicine include the use of sterile, single-use needles to penetrate the skin. Additional treatment methods can include, but are not limited to: acupuncture, acupressure, the electrical stimulation of needles, cupping or moxibustion, gua sha, and tuina. Before any of these procedures are performed, my practitioner will discuss my treatment options and only processed if my consent is given.

2. My practitioner has informed me the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.

3. I will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.

4. I understand that I must let my practitioner know I am carrying, or believe to have any infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.

5. I understand that there are no guarantees for the results of my treatment. Traditional Chinese Medicine does not often provide an instant cure. The length of my treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin to improve.

6. I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered.

7. I discuss the content of this form with my practitioner. I acknowledge that I can ask any questions I may have and receive answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.

By signing this form, I acknowledge that I have reviewed the form with the patient (or substitute decision-maker) and have answered the patient’s (or substitute decision-maker’s) questions.