ACUPUNCTURE INFORMED CONSENT TO TREAT AND RELEASE FORM!FOR SARA BOWES, LAC!!!

I hereby request and consent to acupuncture and associated treatments and procedures having to do with holistic medical care within the scope of practice of acupuncture for myself, (or for the patient named below for whom I am legally responsible) by Sara Bowes, LAc.!!I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, guasha, electro-acupuncture, tuina (Chinese manual therapy), herbal medicine, exercise and/or nutritional and lifestyle counseling and coaching. I understand that herbs may need to be prepared and that teas be consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify my practitioner or a member of the clinical staff of any unanticipated or unpleasant effects associated with the treatment and/or consumption of herbs.!!I understand that acupuncture is a generally safe method of treatment that involves the insertion of subcutaneous needles at various points on the body. I acknowledge that acupuncture may occasionally have some side effects including bruising, numbness, tingling or pain near the needle site that may last a few days, as well as dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps or hot packs. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.!I understand that Asian manual therapy (including all bodywork procedures, cupping, guasha and qigong therapy/energy work) could constitute a wide range of manually applied techniques that could include, but are not limited to, light touch, deep pressure, and joint mobilization through stretching and passive range of motion. I understand that any or all aspects of Asian manual therapy may result in fatigue, nausea, malaise, soreness, bruising and aching for multiple days after treatment and that bruising is a common side effect of cupping and guasha. Emotional release and regression to past traumatic events may also result from any or all aspects of treatment.!!The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that I have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs and other treatment methods may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify my practitioner if I am now or become pregnant or if any of these side effects occur.!!I understand that while this document describes the major risks of treatment, other side effects and risks may occur. As with any medical or health related treatment, I understand that it is impossible to accurately predict how any one person may respond to treatment and I acknowledge that, in extreme and very rare circumstances, adverse side effects may even result in blindness, disability and/or death.!!!!

! !ACUPUNCTURE INFORMED CONSENT TO TREAT AND RELEASE FORM !

FOR SARA BOWES, LAC (continued)!!!I understand that acupuncture and Chinese medicine treatment is not a replacement for diagnostic medical procedures. I understand that an acupuncturist does not diagnose according to standard medical practice, nor should a “Chinese Diagnosis” be considered a replacement for standard medical evaluation or testing. I acknowledge that my practitioner is not a Primary Care Doctor, Medical Doctor, Naturopathic Doctor, Doctor of Osteopath, Doctor of Chiropractic, nor a Doctor of Physical Therapy and does not claim to practice within the scope thereof.!By signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent and release form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.!!I hereby agree to indemnify and hold harmless Sara Bowes, LAc from any loss, liability, damage, judgement awards or costs, including court costs and attorneysʻ fees that may incur due to my participation in said treatment or subrogation suits or claims, whether caused by the negligence of Releasees or otherwise.!!I have carefully read this form and fully understand its contents. All information I have provided in any and all intake forms is true. I am aware this is a release of liability, a waiver of claims, an agreement not to sue, an indemnity, and a contract between myself and the Releasees described herein. I sign it of my own free will.!!!PARENT OR GUARDIAN OR LIAISON OF SUCH, OF A MINOR: I, as parent or guardian or liaison of the below named minor, hereby give my permission for this child or ward to participate as a patient in the above named treatment(s), and further agree, individually and on behalf of this child or ward, to the terms as outlined herein.!!!Printed Name of Patient:________________________________________________________!!Signature: ____________________________________________________Date:___________!!!Parent / Guardian / Liaison Name (please print) and Signature for participants under 18:!!Name:_______________________________________________________________________!!Signature: ____________________________________________________ Date:___________