I hereby voluntarily consent to be treated by, Tianna Hendrickson, M.Ac, L.Ac, with Chinese Medicine procedures through acupuncture treatment. Tianna Hendrickson is a licensed acupuncturist in the state of Hawaii, and has met all of the state and national guidelines in order to hold such licensure.
I understand that acupuncture is performed by the insertion of sterile needles through the skin, or by application of heat to the skin, or by both, at certain points on or near the surface of the body in an attempt to treat body dysfunctions or diseases and to normalize the body’s physiological functions.
I understand that all of my patient records as well as information I share with my acupuncturist will be kept confidential. No records or information will be released without my written consent.
I have been informed and am aware that while acupuncture is a generally safe method of treatment, certain side effects may result. These could include, but are not limited to, some localized bruising, bleeding, dizziness, fainting, temporary pain and/or discomfort, numbness or tingling near the needling sites that may last a few days resulting in temporary aggravation of symptoms in existence prior to treatment. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage or organ puncture. Infection is another possible risk, although Tianna uses sterile disposable needles and maintains a clean and safe environment.
I understand that I should inform my acupuncturist prior to being treated if I believe I might be pregnant.
I am aware that if there is a worsening of my ailment or condition that lasts over 72 hours, if my condition does not improve within the time estimated by the acupuncturist, or if a new ailment or condition appears that I should consult my personal physician.
I understand that no guarantee concerning acupuncture’s use and effects are given to me, and that I am free to stop acupuncture treatment at any time.
None of the foregoing provisions preclude the administration to me of conventional medical therapy by a licensed physician when such therapy is deemed appropriate.
I understand that I will be charged the full agreed upon amount for failing to show up for an appointment(s). I agree to have a credit card on file that will be charged if I fail to cancel the appointment within 24 hours. I understand that I will call to cancel within 24 hours (or more).
I have carefully read and understand all the foregoing and so am fully aware of what I am signing. I have feel free to contact me.
