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Harmony Health Acupuncture & Herbs

Fertility Acupuncture Consent Form

Birthday
Day
Month
Year
Do you have any implantation e.g. pacemaker, metal implant ?
No
Yes
Are you on any medication now?
No
Yes
Do you have any fainting history?
Yes
No

Purpose of treatment

Fertility acupuncture is used to support reproductive health and may be used alongside natural conception, ovulation induction, IUI, IVF, ICSI, or Frozen Embryo Transfer (FET). Treatment aims to support your overall health and wellbeing and may help improve factors related fertility. However, no treatment can guarantee conception or successful pregnancy.


What the Treatment Involves

Your treatment may include one or more of the following:

  • Acupuncture using sterile, single-use disposable needles

  • Electroacupuncture (EA), where appropriate

  • Moxibustion (heat therapy)

  • Cupping therapy

  • Auricular (ear) acupuncture or ear seeds

  • Lifestyle, dietary and self-care advice

The treatment plan will be discussed with you and may be adjusted according to your menstrual cycle, fertility treatment stage, and clinical presentation


Electroacupuncture (EA)

Where clinically appropriate, electroacupuncture may be offered as part of your treatment. This involves applying a gentle, controlled electrical current between selected acupuncture needles to enhance the therapeutic effects of acupuncture. The intensity is adjusted to your comfort level and monitored throughout the treatment.

Electroacupuncture will not be used if it is considered inappropriate or unsafe.


Please inform your practitioner if you have:

  • A pacemaker or implanted electrical medical device

  • Metal implants near the treatment area

  • Epilepsy or a history of seizures

  • A known heart rhythm disorder

  • Any other implanted medical device

  • Any concerns regarding pregnancy


Possible Benefits

Potential benefits may include:

  • Supporting reproductive health and menstrual cycle regulation

  • Improving overall wellbeing and stress management

  • Supporting blood circulation and pelvic health

  • Reducing pain or symptoms associated with menstruation or fertility treatment

Individual responses vary, and no specific outcome can be guaranteed.


Possible Risks and Side Effects

Acupuncture is generally considered safe when performed by a qualified practitioner using sterile disposable needles. Possible side effects include:

  • Mild discomfort during needling

  • Temporary bruising or slight bleeding

  • Temporary soreness or aching

  • Dizziness or light-headedness

  • Temporary fatigue or relaxation after treatment

Serious complications are extremely rare.


Pregnancy and Fertility Treatment

Please inform your practitioner immediately if:

  • You think you may be pregnant.

  • You have had a positive pregnancy test.

  • You are undergoing IVF, ICSI, IUI or other assisted reproductive treatment.

  • There are any changes to your fertility treatment plan or medications.


Treatment will be adapted according to your stage of fertility treatment and pregnancy.


Your Responsibilities

Please inform your practitioner if you:

  • Have any new medical conditions or diagnoses.

  • Start or stop any medications or supplements.

  • Develop a fever or infectious illness before treatment.

  • Experience any unusual symptoms following treatment.

  • Have a pacemaker, implanted medical device, or metal implants.

  • Become pregnant during the course of treatment.


Confidentiality

All personal and medical information will be treated confidentially and stored securely in accordance with applicable UK data protection legislation and professional standards.


Consent

I confirm that:

  • I understand that I have the right to ask questions before and during my treatment. I have the right to decline treatment at any time without affecting my future care.

  • I understand the nature and purpose of fertility acupuncture and electroacupuncture.

  • I understand the possible benefits, risks, and limitations of treatment.

  • I understand that acupuncture is intended to support my health but does not guarantee conception or a successful pregnancy.

  • I agree to inform my practitioner of any changes to my health, medications, fertility treatment, or pregnancy status.

  • I voluntarily consent to receive fertility acupuncture treatment, including electroacupuncture where clinically appropriate.

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