I understand and am informed that, as in allopathic medicine, in the practice of Traditional Chinese Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organs, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment to be in my best interest based on the known facts at the time. Although I am aware that acupuncture and the other procedures used in Traditional Chinese Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.
Appointment Reminders and Follow Up Communication
We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, email or letter.
I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.
Any photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.
I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacies & Procedures information. By signing below I agree to a course of treatment in Traditional Chinese Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.