AcuMediZen
…a modern approach to ancient healing
Charles A. Sylvester, LAc., DiplAc., MSA
(585)764-4343
www.acumedizen.com
PATIENT INFORMED CONSENT
About Your Practitioner: Charles A. Sylvester, L.Ac., Dipl.Ac., MSA, is a licensed New York State
acupuncturist (License Number 004770) and a certified member of the NCCAOM (National
Certification Commission for Acupuncture and Oriental Medicine). He graduated from a three year
Master of Science program in Acupuncture from Bastyr University in Kenmore, Washington.
During his acupuncture school tenure Charlie participated and immersed himself in various
specialty internships. These internships included work at an HIV/AIDs clinic, a low income clinic,
a chronic fatigue and fibromyalgia clinic, and an international clinic. Charlie enjoys working with
people of all ages, backgrounds, medical conditions, etc. He is nonjudgmental and offers a safe
place to relax and let go of all your aches, pains, troubles and worries. In his spare time Charlie
enjoys spending time with his wife, daughter, mini dachshund and toy fox terrier. He also enjoys
playing and watching soccer, camping, playing and listening to various genres of music, watching
movies, eating good food, spending time with his friends and enjoying the outdoors.
Nature of Treatment: Using the principles of Oriental Medicine, the acupuncturist will examine
you by looking, listening, asking questions, and touching. This allows the acupuncturist to record a
full case history. Once an evaluation is made, the acupuncturist may insert very fine acupuncture
needles into a number of points on your body. The purpose of the needles is to stimulate these
various acupuncture points. The needles do not in any way shape or form inject any substance into
the body! The needles used by the acupuncturist are single use, pre-sterilized and disposable. In
some cases, acupuncture may be accompanied by electrical stimulation or the burning of moxa (i.e.
mugwort), a form of heat therapy. Acupuncturists may also use a variety of other techniques such
as infrared therapy (i.e. heat lamps), gua sha, tuina (a form of Chinese massage), and the use of
various oils and liniments in order to enhance the treatment.
Purpose of Treatment: The purpose of treatment is to alleviate any present pain and resolve your
chief complaint. Acupuncture is a health care service that is based on an Oriental system of
medical theory. Diagnosis and treatment are strictly based on these theories and are used to treat
organic and functional disorders as well as promote general wellbeing.
Benefit of Treatment: Acupuncture has been effectively used to treat disease and disharmony for
thousands of years. Currently, the World Health Organization lists approximately forty conditions
that may effectively be treated by acupuncture. These conditions include but are not limited to
musculoskeletal injuries, digestive disorders, respiratory disorders, gynecologic disorders,
genitourinary disorders, neurological disorders, etc. Note: Individual results may vary.
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Use of Disposable Needles: Acupuncture needles are pre-sterilized, single use and made of
surgical stainless steel. After each treatment, needles are disposed of as medical waste. Needles
are never reused. Your practitioner is certified and trained in Clean Needle Technique, which is a
requirement for New York State licensure.
Special Situations: Various acupuncture points are contraindicated during pregnancy so please
notify your practitioner if you are pregnant, might be pregnant, or are trying to get pregnant.
Additionally, you must inform your practitioner if you have a bleeding disorder, wear a pacemaker,
or wear any other electronic medical device.
Confidentiality of Medical Records: All medical records are kept confidential as provided by law.
Your medical records are not released to anyone without your written consent. Your privacy will be
protected.
Risks of Treatment: Acupuncture has been shown to be relatively safe. However, there are some
uncommon and potential risks. These risks may include but are not limited to the following:
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Discomfort during and after needle insertion(a dull, achy sensation is normal; sharp,
stabbing pain is abnormal)
“Needle sickness” (dizziness, fainting, nausea, chills, fever)
Localized, minor bruising or swelling
Minor burns with the use of moxa
Temporary aggravation of symptoms that existed prior to treatment
Broken needle (rare with the use of disposable needles)
Infection (rate with the use of disposable needles)
***Please notify your practitioner if you have any adverse effects from treatment***
Unforeseen Risks: Your practitioner cannot anticipate or explain all possible risks and
complications that may occur during or after treatments. However, he will consider your overall
health and best interests in designing your personalized treatment.
Requirements of New York State Law: By law, your acupuncturist must advise you of the
importance of your seeing a physician. When this is done, you will be asked to sign a form saying
that you were advised of this. You will get one copy of this form, and a second copy will become part
of your record.
Fees, Appointment Cancellation and Late Policy: Cost of the first session (approx. 1.5 hours) is
$90. Additional sessions (45 minutes-1 hour) are $70. Other therapies such as cupping or tuina
are $35 (approx. 30 minutes). Payment is due at the time of each visit. Cash, check and credit (all
major credit cards) are accepted forms of payment. If you must miss an appointment, please call at
least 24 hours in advance. With less than a 24 hour notice I reserve the right to charge half of the
cost of a treatment for the cancelled visit. If you are over 15 minutes late for your appointment
there may not be enough time to do a full treatment. If so, the appointment will need to be
rescheduled and you will be charged half of the cost for the appointment.
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Patient Consent: I, ___________________________________, request and consent to the performance of
acupuncture and other Oriental Medicine procedures. I understand I am free to withdraw my
consent and I may stop treatment or any procedure at any time. I understand my signature on this
form indicates I have read and understand the preceding information regarding my treatment. I
understand if I have any questions about this information or during the course of my treatment, I
should ask my practitioner. I hereby release Charles A. Sylvester, L.Ac., Dipl.Ac., MSA from any
and all liability that may occur in connection with the above mentioned procedures, except for
failure to perform the procedures with appropriate medical care.
Patient’s Name (please print) __________________________________ Date _____________________
Patient’s Signature ______________________________________________________________________
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