I hereby understand that methods of treatment used in this practice may include, but are not limited to, acupuncture, herbal medicine, moxibustion, cupping, electrical stimulation, acupuncture injection therapy, tui na (chinese medical massage), gua sha, heat therapy, ear seeds, ear magnets, dietary advice, therapeutic exercise prescriptions, and lifestyle counseling. I request and consent to the performance of these methods and procedures within the scope of practice set forth by the licensing board on me (or for whom I am legally responsible) by Rhoads to Health Acupuncture LLC, Molly Rhoads AP and/or other providers who now or in the future treat me while employed by, working with or associated with or serving as back up for Molly Rhoads, AP and/or Rhoads to Health Acupuncture LLC.

I understand that acupuncture, herbal medicine, moxibustion, cupping, electrical stimulation, acupuncture injection therapy, tui na (chinese medical massage), gua sha, heat therapy, ear seeds, ear magnets, are all generally safe methods of treatment. Potential mild side effects of acupuncture and acupuncture injection therapy include temporary bruising, swelling, bleeding, dizziness and fainting, numbness and tingling, and soreness at the needle site that may last a few days. An additional side effect of acupuncture injection therapy is an allergic reaction to the solutions used. Temporary discoloration or redness lasting a few days is a common side effect of cupping and gua sha. Very rare risks of acupuncture include spontaneous miscarriage, nerve damage, organ puncture, pneumothorax. Infection is another possible risk, although the clinic uses sterile disposable needles and clean needle technique. Potential but unlikely risks of moxibustion are burns, blistering, or scarring.

I understand that herbal and nutritional supplements recommended to me by my acupuncturist are safe in the recommended doses. Large doses of herbs taken outside of the recommendation of my practitioner may be toxic, and some herbs are inappropriate during pregnancy. I understand that herbs may have an unpleasant smell or taste. Some possible side effects of herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, allergic reaction, rashes, hives and tingling of the tongue. I understand that I must stop taking any herbs and notify my acupuncturist as soon as I experience any discomfort or adverse reactions.

Acupuncture is a natural medicine that works with the body’s ability to heal itself. The results of acupuncture are not always felt immediately, especially with chronic conditions. Frequent, regular treatment is what gives acupuncture and herbs the best results.

I will notify my acupuncturist should I become pregnant or if I am in the process of trying to conceive so that my practitioner can avoid points and herbs that could induce miscarriage. Otherwise, Chinese medicine treatment can be very beneficial in the pregnancy and birthing process.

I understand that I can discuss risks and benefits further with my practitioner. However, I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the practitioner to exercise his or her judgment in my best interest during the course of treatment, based upon the facts then known.

In voluntarily signing this form, I acknowledge any inherent risks, and give my consent for treatment, payment and healthcare operations received, incurred or carried out at this practice. I also certify that I have informed my acupuncturist of all known physical, mental and medical conditions and medications, and I will keep him or her updated on any changes.

I intend that this consent form will cover my current course of treatment and any future treatments.