Acupuncture Consent Form

First Name:
Last Name:

Acupuncture is performed by the insertion of needles through the skin, and/or by the application of heat to the skin at certain points on or near the surface of the body in an attempt to treat pain, disease, or other dysfunction.

Adverse side effects may result. These could include, but are not limited to, local bruising, minor bleeding, fainting, temporary pain or discomfort, and temporary aggravation of symptoms existing prior to acupuncture treatment.

Acupuncturists may recommend treatment with substances from the Oriental Materia Medica. Adverse side effects may result from taking these substances. These include, but are not limited to, changes in bowel habits, temporary abdominal pain or discomfort, and the possible temporary aggravation of symptoms existing prior to herbal treatment. If I experience any problems to which I associate with these substances, I understand that I should stop taking them and call my practitioner.

The above treatment, alternatives, and risks have been reviewed by me and I understand them. I hereby consent to acupuncture treatment.


This policy has been established to help us serve all our patients better.

If you cannot make your appointment, please give us 24 hours notice. Please understand that insurance companies consider this charge to be entirely the patient’s responsibility.

We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible.

A charge of $30.00 will be assessed for each no show or late cancellation office visit appointment if less than 24 hours notice is given.

Patient's Name: