ACUPUNCTURE INFORMATION AND INFORMED CONSENTAcupuncture is performed by the insertion of PRE-STERILIZED, DISPOSABLE acupuncture needles through the skin, and / or the application of heat or electro stimulation to the skin, or both, at certain points on the body. The benefits and risks of receiving acupuncture and Oriental Medicine treatment have been explained to me. Although rare, certain side effects may result from Acupuncture, and I understand that each procedure or treatment has specific risks and benefits.

I have been informed of the risks and benefits of the procedures and products listed below that apply to my treatment:

Acupuncture needles to stimulate points and meridians, including the specific risks of needling certain points

Use of mechanical, magnetic or electrical stimulation of acupuncture points

Moxabustion and liniments

Herbs, nutritional supplements and essential oils

Acupressure, massage, cupping and guasha

I have been informed of and understand the risks and side effects of acupuncture as listed below:

Minor bruising

Needle sickness

Broken needles

Some pain at site of needle insertion

Infection and the risks from needling in the vicinity of an infection

RECORDS RELEASE AUTHORIZATION

I understand that I am responsible for my bill.I authorize the use of this form for all of my insurance submissions.I authorize release of information to all my insurance companies.I permit a copy of this authorization to be used in place of the original.I direct my previous health care providers to release medical records to this clinic.I understand a $37.50 cancellation fee may be charged if I cancel with less than 24 hours notice.I authorize use of the results of my treatment in statistical reports with my identity remaining confidential. I authorize Isthmus Wellness, LLC and any agents representing them to administer care.

Patients Signature _______________________________________________________ Date _____________________

CONSENT TO TREAT A MINOR CHILD

I authorize Isthmus Wellness, LLC and any agents representing them to administer care as deemed necessary

to my _____________________________________________________________ (relationship)._________________

Patients Name ____________________________________________________________________________________

Patients Signature _______________________________________________________ Date _____________________

ISTHMUS ACUPUNCTURE CENTER, LLCCHINESE HERBAL MEDICINE AND MASSAGE

600 Williamson Street, Ste F . Madison, WI 53703608.441.WELL (9355) . 608.441.9395 (fax)www.tcmfertility.com . www.isthmusacupuncture.comisthmusacupuncturellc@gmail.com

515 Junction Rd, Suite 2300Madison, WI 53717608 441.WELL (9355)info@isthmuswellness.comwww.isthmuswellness.com

Isthmus Wellness

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