Acupuncturist Telehealth Consent Form

Acupuncturist Telehealth Consent Form
During the Acupuncture treatment, my medical history, examinations and results can be discussed with other health professionals.
I understand that the treatment is not only limited to acupuncture. The treatment may also include moxibustion, cupping, electrical stimulation, etc..
I can always take my grant back and withdraw my consent back at any time.
All the procedures, potential risks, consequences and benefits have been told tome by the clinic staff. And I have given an opportunity to ask my concerns and questions which have been answered.
Name
First NameLast Name
Phone Number
Email
Birth of Date
MonthDayYear
1
I sign this consent form on behalf of
MyselfMy familySomeone as a legal guardian
Your Name
First NameLast Name
What is your relationship with this person?
Phone Number
Please enter a valid phone number.
Email
Date of Sign
MonthDayYear
2
Signature
Clear
Acupuncturist's Name
First NameLast Name
Acupuncturist's Signature
Clear
Should be Empty: