do hereby voluntarily consent to be treated with acupuncture, adjunct techniques,
and herbal medicine by the licensed acupuncturist Dr. Isaac Goren.
I understand that acupuncture is performed by the insertion of fine sterile needles through the skin at certain points on the body in an attempt to treat bodily dysfunction or disease, to modify or prevent pain perception and to normalize the body's physiological functions. I am aware that certain adverse side effects may result from this treatment. These may include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, the possible aggravation of symptoms and, very rarely, organ puncture including pneumothorax, spontaneous miscarriage, nerve damage or infection.
Moxibustion: I understand that I may receive Moxibustion; the burning of the Chinese herb Moxa (Mugwort leaf) indirectly or directly on the surface of the skin, intending to warm and stimulate Qi and Blood by activating
acupuncture points or channels.
Cupping: I understand that I may receive cupping as part of my treatment. Cupping applies localized suction to the skin with glass or plastic cups, drawing the superficial muscle layer into the cup. It is used to treat pain, relieve stagnation, stimulate the respiratory system, and release heat from the body. I am aware that certain adverse side effects may result from this treatment. These may include, but are not limited to: deep redness, discoloration, bruising, or soreness.
Chinese Herbs: Chinese herbs may be recommended as part of my treatment I understand that I am not required to take these substances but must follow the directions for administration and dosage if! do decide to take them. I am aware that certain adverse side effects may result from taking these substances. These may include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. If I associate any concerns with the use of the herbal substances, I should stop use immediately and call my acupuncturist.
Dietary, Lifestyle & Qi Gong: I understand that suggesting food therapy is an extremely effective means of self-healing, disease prevention, and resolution of chronic and acute conditions. Changing eating habits is difficult and I may experience resistance, irritability, change in bowel movements, change in energy level, and possible aggravation of symptoms. Suggestions concerning physical activity, movement practices and exercises may also be included in my treatment
Release Information
I consent to the use and disclosure of my protected health information for treatment, payment and/or clinic operations. I also permit my treatment sheets to be used as part of the training of students, and understand that to ensure confidentiality a coding system is used and my full name is not included on such a format. I understand that I have the right to revoke this consent in
writing, at any time. The revocation, however, will not affect any disclosures made in reliance of my prior consent
Notice of Privacy Practices and Patient Rights
I acknowledge that I have received a copy of the Notice of Privacy practices and Patient Rights. I have had the opportunity to ask questions about it. All questions I have asked have been fully answered.
