Informed Consent to TCM Diagnosis, Consultation and Treatments at OTCM Acupuncture Clinic
I, the undersigned __ consent to Traditional Chinese Medicine diagnosis and treatments including acupuncture, Chinese herbal medicine in pill form, auricular acupuncture, cupping and other associated modalities by the members of the OTCM Staff. I have discussed the nature and purpose of my treatment with the member of the Clinic’s Medical Staff named below.
I understand that methods of treatment may include, but are not limited to, acupuncture, electrical stimulation, moxibustion, cupping, skin scraping, bloodletting, Tui-Na (Chinese massage), Chinese herbal medicine in pill form, medicated diet, etc.
I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, such as bruising, bleeding, numbness or tingling, or other sensations near the needling sites that may last for a few days, and dizziness or fainting. Bruising and skin marks are common reactions to cupping and skin scraping. Unusual risks of acupuncture include spontaneous miscarriage, tissue damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion.
I understand that while this document describes the major risks of treatments, other side effects and risks may occur. Chinese herbal medicines and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, 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, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. Herbal formulas and acupuncture points may have effects on pregnancy. Patients must inform the practitioner of any possibility of pregnancy.
I understand that the herbs need to be prepared and the tea consumed according to the instructions provided orally and in writing. The herbs may have a strong smell or taste.
I will immediately notify the Clinic of any unanticipated or unpleasant effects associated with the consumption/application of the herbal medicines prescribed and obtained from the clinic. I will notify the Clinic Medical Staff member who is caring for me if I am or become pregnant.
I acknowledge that I have informed my TCM practitioners about my relevant health history, including whether I have any allergies, metal implants, if I suffer from any type of major bleeding disorders, if I have a pacemaker, or if I have any infectious diseases (such as virus, bacterial, or fungi, etc.).I acknowledge that the medical staff and faculty cannot guarantee the results of the treatments. But the nature of the treatment, the expected benefits, risks, and side effects of the treatments, the alternatives of the treatment, and the likely consequences of not having the treatments have all been explained and discussed with me.
I do not expect the Clinic Medical Staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the Clinic Medical Staff to exercise judgment during the course of treatment which the Clinic Medical Staff thinks at the time, based upon the facts they know, and is in my
I understand the clinical medical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
By submitting this consent, I confirm that I have read, or been informed and discussed this consent, to be diagnosed, consulted, and treated, have been told about the benefits and risks of acupuncture and all other TCM procedures/treatments, and have had an opportunity to ask questions.
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 treatments from OTCM Clinic. I understand that I have the right to withdraw my consent to the treatment at any time with clear communication.
I acknowledge that the fees and charges for all the services and purchases for my diagnosis, consultation, and treatments have been explained to me clearly. I understand that the fees charged are not covered under OHIP and must be paid fully by myself. I am responsible for the full and prompt payment after services have been rendered. I could claim reimbursement from my third-party insurance if applicable. There will be no refund for any services rendered and goods purchased.
Cancellation, No-Show, and Purchase Policy
Please be advised that your appointment is booked and reserved for you with our medical staff and care givers. To allow us to serve and help as many patients as possible, as well as maintain smooth operation, we ask all patients to provide us with 24 HOURS NOTICE WHEN CANCELLING or rescheduling appointments. When shorter notice or no-show occurs, the patient will be subject to a $100 FULL SERVICE CHARGE.
Fees for treatment do not include the cost of pills. All herbs and other goods / services are non-refundable after purchase.
This form was created inside of OTCM Acupuncture Clinic.
Exemption of Liability Clause
I, hereby request and consent to receive traditional Chinese medicine treatments including acupuncture, herbal medicine, Tuina massage and other related treatments from student practitioners and supervisors at the OTCM Acupuncture clinic. I acknowledge that the above treatments and all its ramifications have been fully explained to me. I also absolve OTCM staff from the OTCM and its clinic, if I experience any unexpected effects or results from the treatments. I further agree to not commence lawsuit of any kind against all related parties mentioned.