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CONSENT FOR ACUPUNCTURE TREATMENT

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 physician.

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.

PRINT NAME OF PATIENT: _____________________________________________

SIGNED BY: _________________________________________________________

 

 


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