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Harmony Health Acupuncture & Herbs
Acupuncture Consent Form
Birthday
Day
Month
Year
Allergic History
Yes
No
Do you have any implant e.g. pacemaker, metal implant or breast implant?
Yes
No
Are you currently pregnant or have any chance of pregnancy?
Yes
No
Not sure
Do you have history of epilepsy?
Yes
No
Not sure

Treatment Information

I understand that I will be receiving acupuncture treatment performed by Fion Yin Yu Lam (Acupuncturist).

I have been informed that acupuncture involves the insertion of fine needles into specific points on the body to stimulate healing and improve function.


Electroacupuncture

As part of your acupuncture treatment, you may be offered electroacupuncture (EA). This technique involves applying a gentle, controlled electrical current to needles to enhance the therapeutic effects. The intensity is adjusted to your comfort level and monitored troughout the treatment.

Please inform me if you have a pacemaker, implanted electrical devices, metal implant, epilepsy, or if you are pregnant as EA may not be suitable in these circumstances.


Possible Risks and Side Effects

I understand that while acupuncture is generally very safe, possible minor side effects include:

• Mild bleeding or bruising at the needle site

• Temporary soreness

• Dizziness or light-headedness

• Rarely, infection if needles are not sterile (single-use disposable needles are used)

• Very rarely, pneumothorax (lung puncture) with chest needling


My Responsibilities

I agree to inform the practitioner of:

• Any bleeding disorders or blood-thinning medication (e.g., aspirin, warfarin)

• Pregnancy or possibility of being pregnant

• Any changes to my medical history or medications


Consent

I confirm that:

• The practitioner has explained acupuncture treatment and answered my questions.

• I understand the purpose and potential risks.

• I consent to receive acupuncture treatment.

• I may withdraw my consent and stop treatment at any time.


Other Therapies

I understand I may also receive additional therapies (as agreed) such as:

• Cupping therapy (may cause round skin marks or bruising)

• Gua Sha (may cause temporary red marks)

• FIR Lamp heat therapy (risk of minor burns if not used properly)


I consent to these treatments as explained.

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