Acupuncture Informed Consent Form

  • I 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 legally responsible) by Peter Faust. I understand that methods of treatment may include, but are not limited to, acupuncture, cupping, massage and herbal medicine. The herbs may have an unpleasant smell or taste. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including dizziness or fainting, bruising, itching, numbness or tingling near the needling sites that may last a few days. I understand that results are not guaranteed. I understand Peter may keep a record of treatments, but all my records will be kept confidential and will not be released without my written consent.

    Cancellation: If less than 48 hours’ notice is received, half of the appointment fee is requested. If less than twenty four hours is given full cost of the session is requested as it unlikely your appointment can be taken by another.

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