ACUPUNCTURE FOR EVERYONE INFORMED CONSENT TO TREAT
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient for whom this intake is being undertaken, for whom I am legally responsible) by the acupuncturist, Lynette Daudt, LAc, and other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for Lynette Daudt, LAc, including those working at 1002 N 13th Street, Boise, ID, or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, NAET, EFT, qigong (energy healing) and nutritional and lifestyle counseling. Herbs may be prescribed in pill or powder form or in raw, dried form to be cooked as a tea. I understand that, if I choose herbs that need to be prepared as a tea, they need to be prepared and consumed according to the instructions provided orally and in writing. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue.
I will notify my acupuncturist if any of these occur.
I will notify my acupuncturist if I am or become pregnant.
I understand that acupuncture is generally a very safe method of treatment. I also understand that certain after effects may occur including bleeding upon removal of the needles, bruising, numbness or tingling near the needling sites, and dizziness or fainting. These after effects may last a few days. Burns or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is part of the process of cupping, therefore, to be expected.
There are a few risks of acupuncture that properly trained acupuncturists are trained to avoid. These include: spontaneous miscarriage, infection, nerve damage and organ puncture, including lung puncture (pneumothorax). This clinic uses sterile, disposable, single-use needles and maintains a clean and safe environment. Lynette Daudt, LAc, is a fully trained Chinese Medicine Practitioner/Acupuncturist/Chinese Herbalist. Only those with the same training will be employed by or utilized for relief work at Acupuncture for Everyone.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I do not expect my acupuncturist to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on my acupuncturist to exercise judgment during the course of treatment which my acupuncturist thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed and that my participation in my lifestyle and health choices will effect my outcome.
I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
By continuing and completing this online intake, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.