Informed Consent for Acupuncture Treatment I, the undersigned, hereby request and consent to the treatment of acupuncture and/or therapeutic bodywork. I have discussed the nature and purpose of these modalities and understand that no guarantee of cure or improvement in my condition is given or implied. Acupuncture is a technique in which sterile, stainless steel, disposable needles are inserted into specific points on the body to cause a desired healing effect via regulating the flow of "Qi.

 I have been informed that acupuncture is safe, but that it may have side effects, including but not exclusive of, bruising, numbness, or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping and guasha. Unusual risks of acupuncture include miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk and we minimize this risk through promotion of a clean, safe

and single use sterile needles. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.