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Informed Consent for Treatment 

I hereby request and consent to the performance of acupuncture treatments and other Oriental medicine procedures on me (or on the patient named below, for which I am legally responsible) by the below named licensed acupuncturist.  I understand that methods or treatments may include but are not limited to acupuncture, moxibustion, cupping, intradermal needles, ear press balls, bloodletting, electrical stimulation, Tui Na (Chinese massage), Gua Sha, Chinese herb-al medicine, and nutritional counseling. 


Heat therapy using moxa (Artemisia), a dried herb, that is lit and burned on the needles or on the skin, or the use of a heat lamp in conjunction with needle therapy. Moxa is not burned directly on the skin, but on top of a burn ointment which will conduct the heat and prevent burns. On rare occasions, a blister may occur. The practitioner will explain the proce-dure as it is done and the patient is asked to let them know the status of the heat at all times. Application of stainless steel press-balls onto various points in the ear. These are applied with adhesive tape and may be left in the ear for up to 7 days or as suggested by the practitioner. 

Electrical stimulation of the needles using a battery operated machine to create a current through the needles may be used. This creates a constant vibration through the needles that would be adjusted according to patient comfort. 

Cupping is a technique used to resolve muscle tightness or help clear the lungs in respiratory conditions. A glass cup is applied to the skin and then a pump suctions the skin and muscle into the cup. The amount of suction is adjusted accord-ing to patient comfort. Depending on how tight the muscles are and the amount of restricted blood flow. the cups can leave a reddish or purplish mark on the skin that clears up in a few days, similar to a bruise. 

Gua sha is a technique similar to cupping where a flat tool is used to scrape the skin to relieve muscle tension and con-gested blood flow. It leaves a similar bruise-like "rash" that lasts for a few days. 

Herbs 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. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status. If experience any gastrointestinal reactions to the herbs I will inform the acupuncturist immediately. 

holly shuman


Informed Consent

I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. 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 also understand that any evaluation given to me in no way replaces western (allopathic) medical evaluation diagnosis and treatment.

I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to share appropriate medical information. My signature gives my practitioner permission to release my medical records for the reasons listed above. 

I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation. 

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