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Dr. Ashley Kowalski, BSc., Naturopathic Doctor (ND)
1419 Carling Ave. Suite 209, Ottawa, ON, K1Z 7L6
613.761.1600 - info@hamptonwellnesscentre.com
** Please be advised we have a scent-free policy **
Facial Rejuvenation Acupuncture Consent Form
I, _____________________________ understand that by its very nature acupuncture,
and other modalities of Chinese Medicine (including but not exclusive to, acupuncture,
acupressure, massage, herbs, aromatherapy, direct and indirect moxibustion, cupping, and
electrical stimulation), may cause minor discomfort, and may irritate the skin or leave a
mark, bruise, or burn.
There are cases where symptoms may get worse before they get better, and I understand
that if my condition worsens, I should contact the treating acupuncturist and/or seek other
appropriate medical care. In order for better, longer-lasting results, a total of 10-12
sessions are recommended. I understand that I may withdraw from treatment at any time.
I realize no claims, promises, or guarantees are being made, and I accept full
responsibility for the risk and effectiveness of all treatment.
I acknowledge that I have been advised to see a medical doctor or other appropriate
practitioner for my condition(s).
I do not have any of the following contraindications for this treatment:
High blood pressure, migraines, diabetes, cancer, hepatitis, AIDS, hemophilia, a pituitary
disorder such as a tumor, acute cold/flu, allergy, herpes outbreak, pregnancy, intoxication
or hangover from drugs or alcohol.
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Patient Signature
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Practitioner Printed Name
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Practitioner Signature
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