Informed Consent
I hereby request and consent to the performance of the following on myself by the licensed acupuncturists and Chinese medicine practitioners who now or in the future, treat me while employed by, working or associated with Mornington Chinese Medicine
Acupuncture and other Chinese medical procedures including diagnostic techniques such as listening, pulse evaluation, palpation on a variety of areas of my body, observation, range of motion, muscle and orthopaedic testing; modes of manual or physical therapy such as bodywork, structural alignment of joints and/or viscera, heat and/or cold therapy, electric or magnetic stimulation, cupping and/or moxibustion; the prescription of herbal medicines as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle recommendations, and the performance of bodywork therapy.
I am hereby informed that the aforementioned treatment methods are all generally safe but there are some side effects or risks to treatment. I understand that although these risks are very unlikely to occur from a trained and AHPRA registered practitioner, they are possible. I understand that these risks include, but are not limited to:
Acupuncture may potentially cause temporary bruising, swelling, bleeding, numbness and tingling, or soreness at the site of needling. Highly unlikely risks of acupuncture include lung puncture (pneumothorax), nerve damage, organ puncture, and infection - although Mornington Chinese Medicine uses only sterile, disposable needles and maintains a clean and safe environment according to government infection control
guidelines. Potential risks of moxibustion include blistering, burns, and scarring. Common side effect of cupping and guasha are temporary bruising and redness lasting a few days. Cupping can also cause blistering of the skin in some instances. The herbal and nutritional supplements (which may be from plant or mineral sources) recommended to me by my practitioner are generally safe in the traditionally recommended doses. Possible side effects of herbs include nausea, gas, stomachache, diarrhea, and headache. Unusual side effects of herbs include vomiting, rashes, hives, and tingling of the tongue. I understand I must stop taking any herbs and notify my acupuncturist if I experience any discomfort or adverse reaction.
I understand that I can discuss risks and benefits further with my practitioner before signing if I so choose, although I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her judgment in my best interest during the course of treatment, based upon the facts then known.
I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments. I understand that my acupuncturist or any employee, staff, or practitioner associated with this practice may review my medical records and lab reports and all treatment notes from this practice, but all my records will be kept completely confidential. My health information will be handled in accordance with the Australian government privacy policy.
I understand that I am to notify the practitioner if I have an infectious disease, are a haemophiliac, have an existing heart condition, have a pacemaker, are on blood thinning medication, are pregnant, suffer from epilepsy/suffer from seizures, or have any other condition I feel the practitioner should know about.
Please be aware that all information is strictly confidential, and any information you wish not to be recorded should be indicated to the practitioner. By selecting the, 'I agree' box below, I hereby declare that all information that I have provided is accurate and truthful to the best of my knowledge.