top of page

Acupuncture Consent

Patient Information and Consent Form

Please read this information carefully and ask your doctor to explain anything that you do not understand.

What is acupuncture?

Acupuncture is a medical treatment in which fine needles are inserted into specific points on the body to relieve pain and help treat medical disorders. Only single-use, sterile, disposable needles are used for your treatment,

Does acupuncture have side effects?

Acupuncture is generally very safe. Here is a list of common side effects.

  • Minor bleeding or bruising may occur when the needles are removed.

  • Drowsiness may occur after a treatment. If this happens, you should not drive.

  • Symptoms can temporarily worsen after treatment. Be sure to tell your doctor about this at your next appointment.

  • Lightheadedness or fainting may occur, particularly at the first treatment.

Other possible risks are extremely rare. They include infection, nerve injury, broken needle, and puncture of a lung or other organ. If there are particular risks that apply in your case, your doctor will discuss these with you. 

What does your doctor need to know?

In addition to your medical history, it is important to tell your doctor

  • all medications you are currently taking,

  • if you have fainted, had a seizure, or had an unusual reaction to a medical treatment,

  • if you have a pacemaker or any other implanted device,

  • if you have joint replacement, spinal injury, or other surgery,

  • if you have a bleeding disorder or are taking blood thinners,

  • if you have a damaged heart valve or other cardiac problem,

  • if you are at increased risk of infection.

Acupuncture Questionnaire

1. On the anatomical figures (download here), mark the area or areas where you have pain or other problems. Please be as accurate as possible with the locations and upload the graphic.

Shao Yin Fire
Tai Yang Fire

Statement of Consent

I confirm that I have read and understand the above information. I consent to having acupuncture treatment acknowledging that no guarantee of results has been made to me. I understand that I can refuse treatments at any time.

2. List in order of importance the problems you would like the doctor to treat with #1 being the most important.

3. Please check any statements that apply to you at least 80% of the time. Be nonjudgemental and don't think about the answers too much. Leave blank any boxes that do not apply to you or that you are unsure of. There are no correct answers. Your honesty will result in a better treatment.

I have trid these treatments.
Shao Yin Water
Tai Yang Water
Jue Yin Fire
Shao Yang Fite
Shao Yang Wood
Jue Yin Wood
Tai Yin Earth
Yang Ming Earth

Additional information that will be important for the doctor to know:

Your form has been submitted

Yang Ming Metal
Tai Yin Metal
bottom of page