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Chakra Experience and Acupuncture Consent Form

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.