By signing below, I voluntarily consent to receive acupuncture treatment from Dr. Lily Chan, DC, LAc, a licensed acupuncturist, and agree to the following terms:
1. Nature of Acupuncture Treatment
I understand that acupuncture involves the insertion of single-use, sterile needles through the skin at specific points on the body to help regulate and normalize physiological functions.
I understand that acupuncture is generally considered a safe form of treatment; however, certain risks and side effects may occur. These may include, but are not limited to:
- Local bruising
- Minor bleeding
- Soreness or discomfort
- Dizziness or lightheadedness
- Fainting
- Temporary aggravation of existing symptoms
I acknowledge that no guarantees have been made to me regarding the results or effectiveness of acupuncture treatment.
2. Voluntary Participation
I understand that acupuncture is not an exact science and that outcomes may vary between individuals. I acknowledge that no assurances have been made regarding the results of my treatment.
I understand that I am free to discontinue acupuncture treatment at any time.
I voluntarily give my consent to receive acupuncture treatment.
3. Medical Disclosure
I agree to inform the acupuncturist prior to treatment if:
- I am pregnant or suspect I may be pregnant
- I have any relevant medical conditions
- I am taking medications
- I have a bleeding disorder, pacemaker, or any condition that may affect treatment
I understand that it is my responsibility to provide accurate and complete health information.
4. Physician Consultation
I understand that acupuncture treatment is not a substitute for medical diagnosis or medical care. I have been advised of the importance of consulting a licensed physician regarding my medical condition prior to or at any time during acupuncture treatment.
5. Acknowledgment of Understanding
I confirm that I have carefully read and understood all the information above, including the risks and benefits of acupuncture treatment. I have had the opportunity to ask questions and receive satisfactory answers. I voluntarily consent to receive acupuncture treatment from Dr. Lily Chan, DC, LAc, for my present condition and any future conditions for which I seek treatment.
BY PURCHASING A TICKET, OR ATTENDING AN EVENT, I CONFIRM MY AGREEMENT TO THE ABOVE TERMS IN FULL.