Client services and chart information are confidential. Written authorization is required from you to release any information.
• Please turn off your mobile phone for optimal relaxation
• Your scheduled session is set aside for you. We do not double book appointments
• Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee 80%. Less than 24 hours notice will incur a cancellation fee of 100% of the scheduled fee
• You will have a consultation with your practitioner to discuss your session
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.
Draping will be used during the session – only the area being worked on will be uncovered.
Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Integrative Health Chinese Medicine Centre and my practitioner from any liability whatsoever arising from failure on my part.
Informed Consent to Treatment:
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do.
I hereby agree and consent to the performance of acupuncture and other Traditional Chinese and Japanese Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In (Japanese massage), Shiatsu (Japanese massage), Chinese or western herbal medicine, lifestyle, exercise and nutritional counselling.
Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Tui Na (Chinese massage), Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment.
I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable.
I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Chinese and Japanese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan.
This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections or collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility.
I will inform my practitioners immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *