COMMUNITY ACUPUNCTURE CONSENT FORM
Please read and sign the following document and bring it with you on your first visit.
I understand and am informed that acupuncture is generally a very safe procedure and the minor complications that could occur are: 
 • Mild bruising, pain and soreness 
 •
Nausea and fainting when receiving acupuncture 
 • Aggravation of symptoms before getting better
I will inform my practitioner if I have any of the following: 
 • Prone to fainting, seizure or other odd detached sensations 
 • Possible pregnancy 
 • Bleeding disorder 
 • Taking blood thinners 
 • Damaged heart valves or any other particular risk of infection 
 • Current infectious disease(s), e.g., Hepatitis, HIV, TB.
Privacy Policy 
 Information exchanged at the group treatment room may be overheard and I will keep these information private. (You would want others to do the same for you.) I will let the practitioner know if there are topics that need extra discretion.
Cancellation Policy 
 I recognize that scheduling an appointment involves the reservation of time specifically for me and I agree to give at least 24 hours notice to cancel or reschedule an appointment. I will be charged for sessions missed without such advance notification.
I have read and understand the above and hereby give consent to practitioners of
WellBalance Community Acupuncture to perform treatments on me. I was told that the methods of treatment may include but are not limited to Acupuncture, Cupping, flower essences and herbs. I have read the possible risks of treatment outlined above, but do not expect the practitioners to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on my practitioners to exercise judgment during the course of treatment, which, based upon the facts then known, is in my best interests. I am seeing practitioners from WellBalance Community Acupuncture of my own choice. I understand that the Traditional Chinese Medicine offers just one aspect of my health care. I intend this consent to cover the course of treatment for my present and for any future condition for which I seek treatment.
Print Name: _____________________________________________________________________
Signature: _______________________________________________________________________
Date: ______________________________________________________________________________