Deanna Kayyali, L.Ac.
7200 E. Dry Creek Rd, Suite B103
Centennial, CO 80112
(720) 675-8388
www.corneracu.com
Informed Consent to Facial Rejuvenation Acupuncture
By signing this form, I ______________________________________ understand that I will be
receiving facial rejuvenation acupuncture treatments. Acupuncture and other modalities
of Chinese Medicine (including but not exclusive to, acupuncture, acupressure, massage,
herbs, aromatherapy, moxibuston, cupping and electrical stimulation) may cause minor
discomfort and may irritate the skin or leave a mark or bruise. The most common side
effect from facial acupuncture is minor bruising which is temporary, and is treated with
ice and essentials oils (Helichrysum) to minimize size and coloration.
I have been advised that any of the following health issues are contraindications for facial
rejuvenation acupuncture: high blood pressure, migraines, diabetes, cancer, hepatitis,
seizures or epilepsy, AIDS, hemophilia, coronary disease, and pituitary disorders such as
a tumor. I am not pregnant nor do I have an acute headache, cold/flu, and acute
allergies, shingles or herpes outbreak. I acknowledge that I take full responsibility in
informing the acupuncturist, Deanna Kayyali L.Ac., at this time of my health concerns &
conditions. I acknowledge that if I have one of these contraindications and that I still
choose to proceed with the treatment against the advice of Deanna Kayyali L.Ac., I agree
that I am accepting full responsibility for any and all side effects as a result of my
decision.
I understand that certain conditions can affect the degree of results as well as the
longevity of the achieved results such as smoking, sun damage, age, skin care, illnesses,
pharmaceuticals and lifestyle choices (diet, exercise, mental attitude & sleep). Therefore,
I realize no claims, promises or guarantees are being made.
I have read or have had read to me, and I understand the information provided in this
informed consent. I have had an opportunity to ask questions about this consent form
and by signing below, I agree to the procedure of facial rejuvenation acupuncture. I also
release Deanna Kayyali L.Ac., and Cornerstone Acupuncture & Herbal Medicine, LLC
from any and all claims for damages and liability resulting from my treatment.
_______________________________________________
Patient’s name (printed)
_______________________________________________
Patient’s Signature
____________________
Date signed