Informed Consent Agreement- Acupuncture Services

Welcome to the Dempsey Centers for Quality Cancer Care. Our mission is to provide quality of life services to individuals and families impacted by cancer, including acupuncture to address physical symptoms and stress-related symptoms presented by a cancer impact.

If you are reading this form, you have chosen to utilize our acupuncture services.

Acupuncture Services: We provide acupuncture services by licensed acupuncturists. Our acupuncture services are intended for stress reduction and may also help to ease other cancer-related symptoms such as pain, anxiety, fatigue, nausea, insomnia and depression. Acupuncture is not intended to constitute and is not a substitute for medical care. Services will not include diagnosis or prescriptions, and nothing said or done in the course of the acupuncture sessions should be construed as such.

Your first visit will include an assessment, during which you and your acupuncturist will review your health history, determine your concerns and goals, and if both agree to proceed, a plan for further sessions will be developed. Fine needles will be inserted into specific points on the body for treatment. The goal of our acupuncturists is to provide the most effective therapeutic experience available to you that will enhance your quality of life.

Acupuncture sessions are typically 45 minutes in length and we provide up to 8 sessions for patients. Single-use, sterile, disposable needles are used in the clinic.

Risks: Acupuncture is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. Complications may arise from receiving acupuncture, including soreness during or after needle insertion and/or with needle withdrawal, minor bruising or bleeding where the needles are inserted, localized infection, feeling faint or fainting, fatigue, nerve injury, punctured organ, dizziness and/or vertigo, and headaches/migraines. Drowsiness may also occur after treatment, and if affected, you are advised not to drive. If your symptoms worsen after treatment you should contact us and tell the acupuncturist.

Contraindications: Certain contraindications may exist to acupuncture, and it is your responsibility to inform your acupuncturist if either (i) you have any of the following: a contagious disease, a fever, have lymphedema, have a bruising or bleeding disorder, have platelet counts lower than 10,000 (thrombocytopenia), white blood cell counts lower than 1,000 (neutropenia), have a history of seizures; or (ii) you are pregnant; or (iii) you have recently been vomiting or if you are taking anticoagulant medications.

If any of these conditions exist, acupuncture may not be appropriate for you at this time.

My signature on this Informed Consent Agreement for Acupuncture Services indicates that I:

• Have reviewed, understand, and consent to the policies and information above
• Have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me
• Consent to receive acupuncture services for myself
• I understand that I may stop such treatment or services at any time
• Agree that I will inform my acupuncture therapist if I have any of the conditions or risks listed above under “Contraindications”
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I understand that my typed name above will carry the same effect as my written signature(Required)