Informed Consent For Acupuncture Care Form

THE BRIGHT PHYSIO & MINDFULNESS MASSAGE

Unit #105, 4904 30 Avenue, Beaumont, Alberta T4X 3G3

Phone: 780-737-1019 Fax: (844) 777-1796 Email: thebrightphysio@gmail.com Website: www.thebrightphysio.ca

INFORMED CONSENT FOR ACUPUNCTURE CARE

Please Read Carefully

I hereby request and consent to the performance Of acupuncture and, where clinically appropriate and within the treating
practitioner's authorized scope of practice. procedures related to acupuncture. These may include moxibustion. cupping and/or
electroacupuncture.

Nature and Purpose Of Treatment

Acupuncture involves the insertion Of fine. sterile needles into selected points Of the body. The practitioner Will discuss the
proposed treatment plan. the purpose of treatment. and reasonable expectations before treatment is provided.

Potential Benefits

Depending on the condition being treated, acupuncture may help reduce pain or discomfort, reduce muscle tension, improve
function, and support other treatment goals discussed with the practitioner. Individual responses vary and results are not
guaranteed.

Risks and Possible Side Effects

I understand that acupuncture and related procedures have potential risks and side effects. including but not limited to:

• Minor bleeding, bruising, tenderness, pain or soreness at the needle site.

• Temporary dizziness, light-headedness, nausea or fainting.

• Temporary worsening of symptoms or fatigue following treatment.

• Infection, although appropriate infection.prevention procedures are used.

• Burns skin irritation associated With moxibustion, heat or related techniques.

• Stuck, bent or broken needles.

• Nerve irritation or injury.

• Rare but serious injury such as puncture of an internal organ or lung (pneumothorax).

• Other uncommon or unexpected reactions that may require medic

Sterile Needles and Infection Prevention

I have been advised that only pre-sterilized, single-use disposable acupuncture needles will be used and that used needles will be
disposed of appropriately after each treatment.

THE BRIGHT PHYSIO & MINDFULNESS MASSAGE

INFORMED CONSENT FOR ACUPUNCTURE CARE

Alternatives

I understand that alternatives may include no treatment. observation. modification of activity, exercise, physiotherapy. massage
therapy. chiropractic care, medication, medical assessment or Other treatment options depending on my condition.

Fees and Costs

I understand that the fees for acupuncture treatment and any related services Will be explained to me before treatment. I am
responsible for charges not covered reimbursed by my insurer or other payer.

Questions, Changes and Withdrawal of Consent

I have had the opportunity to ask questions about the proposed treatment. expected benefits, material risks. alternatives and
costs. I understand that I may ask questions at any time and may refuse or withdraw my consent to treatment at any time. I will
inform the practitioner of any significant change in my health, symptoms, medications or medical history.

Pregnancy | Possible Pregnancy

If I am pregnant, may be pregnant, or become pregnant during the course of care, I will inform the treating practitioner before
treatment so that the treatment plan can be reviewed and modified as appropriate.

Consent

I understand that it is not possible to anticipate or explain every possible risk or complication. I authorize the treating practitioner to
use professional judgment during treatment based on the information available at the time and within the practitioner's authorized
scope of practice.

READ BEFORE SIGNING