Consent to Treat

  • Informed consent to treatment

    I hereby voluntarily request and consent to be treated, or give permission for the person on whose behalf I am signing below to be treated, with acupuncture and other techniques based on Chinese medicine. I understand I may be given diet/lifestyle recommendations and/or herbal supplements and that it is my decision whether or not to follow these recommendations. The procedures involved in this treatment have been explained to me. I have not been guaranteed any success concerning the uses and effects of these treatments. I understand that I am free to refuse any treatment or procedure, and to discontinue my treatment at any time.

    Possible side effects

    I understand that these treatments may result in certain side effects, including local bruising, slight bleeding, dizziness, fainting, burns, temporary pain or discomfort, and temporary aggravation of symptoms existing prior to treatment. Unusual and rare risks of acupuncture include nerve damage, organ puncture, and infection. I have read the information on this page and understand the possible risks involved. I understand that herbs may taste unpleasant and may occasionally cause symptoms such as bloating, cramping, or diarrhea. I understand it is my responsibility to inform my practitioner of any such side effects, and that my herbal prescription will be changed or stopped accordingly.

    Medical referral

    I understand that treatment from this practitioner is not a substitute for appropriate medical treatment by a licensed physician. I have been advised that if there is a worsening of my ailment or condition, or if it does not improve within the time estimated by the acupuncturist at the beginning of treatment, or if a new ailment or condition arises, it may be necessary for me to consult a licensed physician. If I am presently under the medical care of a physician, I have been advised to continue all medications and treatments as prescribed until such time as my physician deems it appropriate to reduce or discontinue the medications or treatments. I certify that I have informed Rachel Pagones, L.Ac. of all of my known physical, mental, and medical conditions and medications, including possible pregnancy, and that I will notify her of any changes.

    Clean needle technique

    I understand that infectious disease is carried through the air, through physical contact, and through body fluids. I understand that universally prescribed precautions will be followed during treatments to guard against the spread of infection, including the use of sterile, prepackaged disposable needles. Needles that are used for my treatment are used only on me, and are inserted according to nationally prescribed standards for cleanliness. Needles are disposed of as medical waste immediately after use. I understand that my questions about the safety of any procedure or treatment or the precautions taken by the practitioner are welcome and will be answered as fully as possible. I have read this form carefully, or had it read to me in full, and I have felt free to ask questions regarding my treatment.

  • Note a physical signature will be required at time of visit.