PURPOSE: The purpose of the "Informed consent for TCM(Traditional Chinese Medicine) treatment and care" is to gain the patient's consent in order to participate in treatment appointments.

HEALTH INFORMATION: The medical information related to the history, records, and tests of the patient will be discussed during the appointment and treatment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask questions related to appointments and treatment.

I hereby request and consent to the performance of acupuncture, herbal medicine treatments, and other Traditional Chinese Medicine procedures on me (or on the patient named below, for whom I am legally responsible) by a licensed Chinese Medicine herbalist or acupuncturist.

I understand the methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), bloodletting, and Chinese herbal medicine. I have had the opportunity to discuss with the above-named acupuncturist the nature and purpose of TCM treatments and other procedures. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness, or tingling near the needling sites that may last a few days, with possible dizziness or fainting. Bruising is a common side effect of cupping. Burning, scarring or blistering of the skin are rare complications as a result of moxibustion or TDP lamp use. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). I understand that the risk of infection is negligible when all needles are sterile. The herbs in raw, granules, and pills (which are from plant, animal, and mineral sources) that may be recommended are traditionally considered safe, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. I understand that the herbs need to be prepared and the herbal medicine should be consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately inform the TCM practitioner of any unanticipated or unpleasant effects associated with the consumption of the herbal teas. I will notify the practitioner who is caring for me if I am or become pregnant. I will notify the practitioner about having a pacemaker or metal implants if applicable.

I do not expect the TCM practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the TCM practitioner to exercise judgment during the course of the procedure, which the TCM practitioner feels, based on the facts then known, is in my best interests. I understand that while every effort will be made to achieve optimal outcomes, no guarantee has been made regarding the success of the treatment.

I understand that it is my responsibility to proactively inform my practitioner about any high-risk conditions I may have. These conditions include, but are not limited to, infectious diseases, pregnancy, heart failure, epilepsy, bleeding disorders, severe diabetes, or severe allergies. By disclosing my medical history, I aim to minimize my healthcare risks and ensure that I receive the most appropriate and safe medical care.

I understand that TCM treatments aim to help improve disease symptoms but do not provide direct Western medical diagnoses. Therefore, it is the patient's responsibility to seek a Western medical diagnosis to rule out potential dangers, such as fractures or severe infections. Under no circumstances will TCM practitioners guide the Western medical treatment or medication. Any related questions should be directed to my Western medical provider. I understand that Traditional Chinese Medicine is not intended to replace emergency medical care or Western diagnosis, and I am responsible for seeking appropriate medical advice when necessary.

I understand that the practitioner may take clinical images, such as tongue or body photos, for diagnostic or medical record purposes. De-identified images may also be used for education or professional case sharing in an anonymous format. No identifying personal information will ever be disclosed. If I do not wish my de-identified images to be used for such purposes, I will inform the practitioner at any time.

I agree that the practitioner may do a pulse check, abdominal check, and meridian check for TCM diagnoses. I understand the clinical and administrative staff may review my medical records and lab reports, but all my personal information in the record will be kept confidential and will not be released without my written consent. I understand that I can refuse treatment or any specific type or part of acupuncture and other TCM treatment methods at any time by informing the practitioner.

I have read, or have read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

I have read and agree with [Terms&Conditions], [Privacy].