I, hereby request and consent to the performance of acupuncture and other related techniques, as necessary, including dry needling (GTT technique), moxibustion, cupping, electro-acupuncture, laser therapy and/or magnetic therapy as the physiotherapist feels necessary.
Moxibustion – whereby herbal heat is applied to specific acupuncture points.
Cupping – whereby suction cups are applied to specific points on the body.
Electroacupuncture – whereby the needles are electrically stimulated at various high frequencies to cause relaxation of the muscles and analgesia of the area of pain involved.
Laser Therapy – where helium, neon and infrared heat are applied to acupuncture points and different areas of the body where there is trigger point activity.
Magnetic Therapy – whereby magnets are applied on acupuncture points and on tender trigger points.
Before treatment, ensure that you have had a light meal within the previous few hours. Avoid smoking and consumption of alcohol or caffeine for a few hours before and after treatment.
I further state that the following contraindications are not existent: Pregnancy; Pacemaker; Anticoagulants; Bleeding disorders; Local infections.
I understand and am informed that in the practice of acupuncture there are some risks to treatment including but not limited to: minor bleeding or bruising, minor pain or soreness, nausea or fainting. These symptoms are temporary in nature. On rare occasions infection, convulsions, possible perforation of internal organs, and stuck or bent needles could occur.
I have been advised that only single use, sterile, disposable needles are to be used. All acupuncture needles are properly disposed of after each and every treatment.
I do not expect the acupuncture practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the practitioner to exercise judgement during the course of the treatment based upon the facts then known, for which he/she feels at the time to be in my best interest. I understand that the results are not guaranteed.
I have read the above consent form. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above mentioned acupuncture procedures.