Informed Consent for Treatment

I understand that I am the decision maker for my health care.

Part of the role of the clinicians at Dr. Constance Bradley Acupuncture is to provide me with information to assist me in making informed choices. This process is often referred to as ‘informed consent’ and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care.

Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary, urgent, or emergency medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture as defined by ARS Title 32, Chapter 39, Sec: 32-3901-32-3955 on me (or on the patient named below, for whom I am legally responsible) by Dr. Constance Bradley and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the Dr. Constance Bradley, including those working at the Dr. Constance Bradley Acupuncture 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, gua sha, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, Acupuncture Injection Therapy (AIT) and nutritional counseling.

I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is generally a safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting.

Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps.

Bruising is a common side effect of cupping and gua sha.

I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. 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 side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue.

I understand that it is my responsibility to inform my clinician if I’ve ever experienced any of the following,

Fainting

Seizures

Bleeding disorders

Taking prescription anticoagulants or any other medication

Damage to a heart valve or any cardiac pathologies

Increased risk of infection

I will notify a clinical staff member who is caring for me if I am or become pregnant.

I understand the clinical and administrative staff may review my patient records and lab records, but all of my records will be kept confidential and will not be released without my consent, unless permitted by law.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based on the facts then known, is in my best interest. I understand that results are not guaranteed and there is no promise to cure.

I understand that in the event that my condition is such that treatment is beyond the normal capabilities of the Acupuncturist, I understand that I may be referred to other competent practitioners including, but not necessarily limited to, medical physicians or other. I also understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

I have read, reviewed, understand, and agree to 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 agree with the current or future recommendations for care. I intend this consent to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. I understand that I can refuse treatment at any time.