*ACUPUNCTURE COUNCIL OF ONTARIO
Please read carefully. I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture, as necessary, and including moxibustion, cupping, and/or electro acupuncture by the practitioner or another duly authorized practitioner in the clinic. I understand and am informed that in the practice of acupuncture there are some risks to treatment including but not limited to, minor bleeding or bruising, minor pain or soreness, nausea, fainting, infection, shock, convulsions, possible perforation of internal organs, and stuck or bent needles.
I have been advised that only pre-sterilized needles are to be used. All acupuncture needles are properly disposed of after each and every treatment.
I do not expect the practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the practitioner to exercise judgment during the course of treatment which the practitioner feels at the time, based upon the facts that are known, is in my best interests. I understand that the results are not guaranteed.
I have read the above consent form. I have also had the opportunity to ask questions about its content and by signing below I agree to the above mentioned acupuncture procedures. I intend this consent form to cover the entire course of treatment for my present and future conditions for which I seek treatment.
N.B. Female Patients:
I fully understand that in the case of pregnancy, a risk causing fetal distress with acupuncture treatment(s) is possible. I hereby state that I am not pregnant, nor is there any possibility that I may be pregnant.