Consent Form - Acupuncture by Chiropractor

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INFORMED CONSENT FORM

ACUPUNCTURE CARE BY CHIROPRACTOR

PATIENT INFORMATION

Patient ID: _________________

First NameYour First Name

Last NameYour Last Name

It is important for you to consider the benefits and risks and alternatives to the acupuncture treatment offered by your chiropractor and to make an informed decision about proceeding with treatment.

Acupuncture involves the insertion of small sterilized needles into specific locations on the skin surface. Other procedures related to acupuncture include moxibustion, cupping and electroacupuncture.

BENEFITS

Acupuncture and procedures related to acupuncture have been demonstrated to be a safe and effective form of treatment for a range of conditions including musculoskeletal complaints and pain.

RISKS

The risks associated with acupuncture include minor bleeding and bruising, temporary pain and soreness, nausea, fainting, burns, infection, shock, convulsions, pneumothorax, perforation of internal organs, and stuck or bent needles.

Please inform the chiropractor if you:

● Have or develop any major health issues

● Are pregnant or actively trying to be

● Have been fitted for a pacemaker or other electrical implants

● Have a bleeding disorder or take anticoagulants

● Have damaged heart valves or have a high risk of infection

● Suffer from metal allergies

● Have had prosthetic implants

● Are Immune compromised

Only sterile single use disposable needles will be used. All acupuncture needles are properly disposed of after each and every treatment.

PREGNANCY

The use of certain acupuncture points and treatment techniques may not be recommended during pregnancy. Advise your chiropractor if you are pregnant or actively trying to be.

ALTERNATIVES

Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment.

QUESTIONS OR CONCERNS

You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time.

PLEASE BE INVOLVED IN AND RESPONSIBLE FOR YOUR CARE. INFORM YOUR CHIROPRACTOR IMMEDIATELY OF ANY CHANGE IN YOUR CONDITION.

CANCELLATION or NO SHOW POLICY

We, at Physiomobility are here to provide you with the very best care and attention. We understand that unforeseen events and emergencies occur in everyone’s lives. Out of respect for both your practitioners and your fellow patients we ask that you do your very best to arrive on time and to notify us as early as possible in the event that you are unable to attend. Last minute cancellations and no-shows affect our ability to provide an outstanding experience to all of our patients.

In consideration for our therapists’ time, we have adopted the following policy:

If for any reason you need to cancel or re-schedule your appointment with us, we require a minimum of 24 hours notice for change or cancellation of any appointment. This will allow us to fill the available time slot with another patient who needs our services. A full amount of the service fee will be charged for late cancellation/no show if you cancel the same day or if you do not show up for your appointment. Please note that this fee is not billable to insurance policy and remains your responsibility.

SIGN & SUBMIT AFTER DISCUSSING TREATMENT PLAN WITH YOUR CHIROPRACTOR

by Electronic Signature

DO NOT SIGN THIS FORM UNTIL YOU MEET WITH YOUR CHIROPRACTOR

I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment.

By typing my name (Patient or Guardian's full name) below, I am electronically signing this form and consent to acupuncture treatment as proposed to me.

Patient or Guardian Full Name

Date

Chiropractor Signature

Chiropractor Full Name

Date

Copy of this form?

If you would like to receive a copy of this signed consent form, please provide an email address below:

Your Email (Optional)a valid email