Boise Community Acupuncture & Resonance Natural Health
Frances Towle, L.Ac. , Hector Perez, L.Ac., Sean Peachey, L.Ac.

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INFORMED CONSENT TO TREATMENT (Please download PDF to the right to sign and date)
I consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine, or Nutritional Programs by Frances E Towle, L.Ac, Hector E Perez, L.Ac, or Sean Peachey, L.Ac. I have discussed the nature and purpose of my treatment with the above named practitioner.

I understand that the methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Massage), Mud Pack Therapy, and Nutritional and Herbal Counseling.

I have been informed that acupuncture is a safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this clinic uses sterile, disposable single-use needles, and maintains a clean and safe environment. Burns and/or scarring are a potential risk of
moxibustion. I understand that while this document describes the major risks of treatment, other side effects may occur.

The herbs and nutritional supplements that have been recommended are generally considered safe, although some may be toxic in large doses. I understand that some herbs and supplements may be inappropriate during pregnancy. I will immediately notify Boise Community Acupuncture & Resonance Natural Health’s Practitioners of any unanticipated or unpleasant effects associated with the consumption of herbs or nutritional supplements.

I understand that practitioners at Boise Community Acupuncture and Resonance Natural Health provide acupuncture, herbal and nutritional consultations, and other health related information to help me attain and maintain my best health. Boise Community Acupuncture and Resonance Natural Health’s practitioners will help determine which nutrients my body needs bolstered. All recommendations are designed to help me move towards my best state of health through personalized recommendations in lifestyle, exercise, health habits and nutrition. I understand that Boise Community Acupuncture and Resonance Natural Health’s practitioners are NOT medical doctors and DO NOT diagnose, treat, or claim to cure cancer or any other disease.

I will notify Boise Community Acupuncture and Resonance Natural Health’s Practitioners if I am or become pregnant.

I do not expect Boise Community Acupuncture and Resonance Natural Health’s Practitioners to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the above named practitioner to exercise judgment during the course of treatment which he or she thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.

I understand the clinical, medical, and administrative staff may review my medical records and lab reports, but all my records
will be kept confidential and will not be released without my written consent.