1. I understand that the professional practitioners (acupuncturists) in Top Rehab will treat my conditions within their scope of practice of Traditional Chinese Medicine (TCM), which may limit treatment choices.
2. I understand that “Acupuncture” treatment involves the penetration of skin by sterile, one-time-use, disposable filiform needles. There are additional methods of treatment, within the scope of acupuncture and “Traditional Chinese Medicine” that may be used in addition to, instead, or in combination with needles. The scope includes:

• 1) Assessment by the collection of data by interviewing, observation, palpation, pulse taking, tongue observation and other methods;
• 2) Acupressure and therapeutic massage (Tui-Na, (Chinese massage));
• 3) Dietary herbal supplements and Chinese or Western herbal medicine;
• 4) Nutritional counseling;
• 5) Energy-flow work, exercises or other prescribed forms of movement (e.g. Qigong, Tai Chi);
• 6) Heat therapy with the use of mugwort (moxibustion) or a heat lamp over localized areas;
• 7) Glass cups “fire- cupping”, plastic suction cups;
• 8) Gua Sha tools for scraping;
• 9) Electrical stimulation of acupuncture needles
• 10) LED (Light therapy)

3. I understand that as the patient, I must inform the practitioners of medications, medical history, and sensitivities to smoke or scents, if I am currently pregnant, have a bleeding disorder or any communicable or contagious conditions that could be passed to others.
4. I understand that I must lie still during treatment; am responsible to ask questions regarding treatment details if explanations provided are not clear or understood; have a right to refuse treatment at any point.
5.  I understand that patients are advised to tell their doctor they are receiving TCM acupuncture, to avoid possible treatment conflicts. Patients are encouraged to report their outcomes to their doctors.
6.  I understand that the assessment, diagnosis, and treatment of medical conditions by TCM varies from Western medicine.
7.  I understand that I must give the clinic 24 hours’ notice of cancellation otherwise I may be charged the full session fee.
8. I understand that acupuncture does not typically provide an instant cure. For most serious or chronic ailments, more than one treatment, along with some lifestyle and dietary changes, may be necessary for noticeable changes to take place.

• • I understand that there is risk of side effects, which may include:
  • Pain
    Acupuncture needling may cause an initial “prick” as it punctures the skin followed by a temporary achy sensation, numbness, or tingling at or near the needling sites that may radiate. These are all normal needling sensations and may last a few days. Please tell your practitioner if any sensation is too strong so they can adjust the treatment accordingly.
  • Tui-Na (Chinese Massage), acupuncture insertion, acupuncture stimulation, electro-acupuncture, cupping, Gua Sha, qigong (exercise), may all cause pain. Patient feedback is important for the practitioner to adjust the treatment when necessary; Electrical stimulation of acupuncture needles produces a mild vibration/tapping sensation on the needles, which may be painful;
  • Bruising
    Bruising may occur anytime we puncture the skin. If you have bruises on some area of the body, please inform your practitioner. The normal reaction of cupping, “gua sha” and scraping is to leave red marks or bruising. This will usually slowly resolve on it’s own with 5-10 days and is part of the intentional therapeutic effect.
  • Infection
    It is possible to develop an infection whenever the skin is punctured despite using single use disposable needles and clean needle technique. Please inform us if you have a known immune problem so we can take special precautions.
  • Burns & Smoke Irritation
    Heat therapy and moxibustion may cause redness, blistering or unintentional burns and/or scarring. It is important to verbally communicate with your practitioner if any heat therapy feels too hot. Smoke from moxibustion may cause coughing, lung irritation, headaches or allergic reactions for those sensitive to scents or smoke;
  • Feeling of Relaxed or Sleepy
    It is common to feel relaxed or sleepy after treatment so avoid getting up too quickly and rushing anywhere directly after treatment. Give yourself time to adjust after treatment before driving or using the stairs or any other potentially dangerous activity.
  • Dizziness & Fainting
    Dizziness or fainting can occur as a result of treatment. Please tell us if you are prone to fainting. Important factors that can decrease this risk include ensuring you have had sufficient food, ensuring you have not had any drugs or alcohol prior to treatment, communicating if the stimulation is uncomfortably strong, and getting up slowly after treatment.
  • Dizziness & Fainting
    Dizziness or fainting can occur as a result of treatment. Please tell us if you are prone to fainting. Important factors that can decrease this risk include ensuring you have had sufficient food, ensuring you have not had any drugs or alcohol prior to treatment, communicating if the stimulation is uncomfortably strong, and getting up slowly after treatment.
  • Content
  • Revoking consent

I understand that this initial consent is to educate and explain my treatment and that I may verbally revoke my consent to any treatment at any time.

• I therefore agree to waive any rights for legal liability that I could have against “Top Rehab” and/or the acupuncture therapist.
• I hereby request and give consent for treatment at the “Top Rehab” using modalities within the scope of “Acupuncture” and “Traditional Chinese Medicine” as described above.
• By signing below, I confirm I have read, understood, asked questions and agree to the above Terms of Treatment.