I herby voluntarily consent to be treated by
Acupuncture administered by Daniel I. Ebaugh, M.Ac., L.Ac., an
acupuncturist registered in the State of Maryland.
The procedures involved in this treatment have been
fully explained to me. I understand I may be treated with the
insertion of needles, and /or with the application of heat to the
skin. I further understand that the Federal Government has deemed
the use of Acupuncture “experimental” as it is not yet a common
practice in this country.
I am aware Acupuncture may result in certain side
effects including local bruising, slight bleeding, fainting,
temporary pain or discomfort, and temporary aggravation of symptoms
existing prior to treatment.
Conventional medical therapy may be used in an
emergency or as deemed necessary in the discretion of the licensed
I have not been guaranteed success concerning the
uses and effects of Acupuncture. I understand I am free to
discontinue treatment at any time.
I am aware that if there is a worsening of my
ailment or condition or if it does not improve within the time
estimated by the acupuncturist at the beginning of treatment, that I
should consult a licensed physician.
I have read this form carefully and I have felt free
to ask any questions I have regarding this process and it as been
satisfactorily explained to me.