All Information is Strictly Confidential

Informed Consent to Receive Acupuncture

By signing below, I hereby authorize Jean Drummond, L.Ac., acupuncturist licensed in the State of California, to perform Chinese Medicine procedures. The scope of practice under acupuncture licensure in California may include insertion of sterile needles, electro-stimulation, heat, cupping, dermal friction, acupressure, herbal therapies, nutritional counseling, breathing techniques and exercise; all of these according to Oriental medical principles.

I understand that Jean Drummond, L.Ac. uses only sterile disposable needles and maintains a clean and safe environment. Herbs and nutritional supplements which may be recommended are traditionally considered safe in the practice of Chinese Medicine.  I wish to rely on her judgment during the course of the treatment, which she feels at the time, is in my best interest. 

I have been informed that acupuncture is a safe method of treatment, but occasionally, while not common, may include the following: minor pain or soreness in the treatment areas that may last up to a few days, temporary bruising or swelling, sensations of heat/cold/ tingling or numbness, skin irritation or slight bleeding at needle site, generalized fatigue, or temporary aggravation of symptoms.  I also understand that there are very rare side effects to acupuncture that may include the following: infection at needle site, needle sickness (dizziness, nausea, fainting), broken needles, or pneumothorax. I understand that while this document describes the major risks of treatment, other side effects may occur.

I agree to contact Jean Drummond, L.Ac. immediately if I experience any problem which I associate with the treatments listed above and will seek immediate help from a physician / hospital if I experience a medical emergency. During the course of treatment, I agree to inform my her of all health issues and medication changes.

By signing below, I agree to the above-named procedures. 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 agree to cover any expenses associated with my acupuncture treatments at the time of treatment. I understand that if I am unable to give 24 hours' notice in canceling an appointment, I will pay for the missed appointment (unless there is an emergency-then the fee is waived.)