• I authorized release to consent to collect use and disclosure my personal health information
• I hereby consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legality responsible" by the registered acupuncturist who now or in the future will treat me.
• I understand that methods may include, but are not limited to, acupuncture, cupping, electrical stimulation, acupressure. Tui-na (Chinese massage), and Chinese herbal medicine oils or creams.
• I have been informed that acupuncture is a generally safe method of treatment, but it may have some side effects that may last a few days including bruising, soreness, numbness, tingling near the needling sites, dizziness, or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture and infection. The spa uses sterile disposable needles and maintains a clean and safe environment.
• I understand the acupuncturist may review my patient records and lab reports, but all may record will be kept confidential and will not be released without my written consent. Also, I have the right to stop the treatment at any time and at any reason.
• I consent to a health assessment/reassessments and acupuncture treatment at Vitality Massage and Spa.
• By voluntarily signing below, 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.
• I attest that the information I have provided is true and complete to the best of my knowledge.
• I understand that the Acupuncturist can end treatment at anytime due to inappropriate behaviour.
• I understand 24 hours notice is required to reschedule all future appointments, or full charges will apply.