Informed Consent

Sample Form

Informed Consent for Acupuncture Treatment

Michael K. Sedgewick, EAMP

In accordance with state law (WAC246-802-120), I bring forth the following information to your attention:

 

1. Practitioner’s Qualifications:

    a. Masters of Science in Acupuncture and East Asian Medicine

        Bastyr University in Kenmore, Washington, 2015

    b. East Asian Medicine Practitioner License #AC60643549     (WA State DoH)

    c. NCCAOM Diplomat in Oriental Medicine (Acupuncture & Herbology)

 

2. Scope of Practice: 

The scope of practice for an EAMP in Washington state includes but is not limited to the following techniques: a. Use of acupuncture needles to stimulate acupuncture points and meridians. b. Use of electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians. c. Moxibustion (heating a point by burning an herb or herbal formula). d. Acupressure (manual therapy on acupuncture points and meridians). e. Cupping (glass or plastic cups placed on the skin using heat or mechanical means to create a vacuum). f. Gua Sha (dermal friction caused by scraping the skin with a blunt object). g. Infra-red therapy (therapeutic heat lamp). h. Sonopuncture (tuning forks, singing bowls). i. Tui Na (soft tissue manipulation and joint mobilization) j. Laserpuncture (stimulation of acupuncture points with laser light). k. Dietary advice based on traditional Chinese medical theory.

 

3. Side Effects:

    The following side effects may occur and are not limited to the following: a. Some pain following treatment in the insertion location (uncommon). b. Minor bleeding from insertion location (occasionally). c. Minor bruising (occasionally). d. Infection (rare). e. Needle sickness: feeling faint or dizzy (rare). f. Broken needle (almost unheard of).

 

4. Patients with Severe Bleeding Disorders or Pace Makers

    Patients with severe bleeding disorders or pace makers should inform practitioners prior to treatment. In accordance with WAC246-802-110: 

 

5.  If you are affected by any of the following conditions, I am required to request that you consult with a physician and provide a written diagnosis from same or have the physician call me:

a. Cardiac conditions including uncontrolled hypertension; b. Acute abdominal symptoms; c. Acute undiagnosed neurological (numbness or tingling, etc.) conditions: d. Unexplained weight loss or gain in excess of 15% body weight with in a three month period; e. Suspected fracture or dislocation; f. Suspected systemic infection; g. Any serious undiagnosed hemorrhagic (bleeding) disorder; h. Acute respiratory distress without previous history or diagnosis, or i. Cancer.

 

*** Please inform me if you suspect or know you are pregnant. ***

 

* To reduce the possibility of infection, all needles are pre-sterilized, single-use needles made of surgical stainless steel.

 

I understand that acupuncture and Chinese medicine treatment is not a replacement for diagnostic medical procedures. I understand that an EAMP does not diagnose according to standard medical practice, nor should consultation with an EAMP be considered a replacement for standard medical evaluation or testing. I acknowledge that my practitioner is not a Primary Care Doctor, Medical Doctor, Naturopathic Doctor, Doctor of Osteopath, Doctor of Chiropractic, nor a Doctor of Physical Therapy and does not claim to practice within the scope thereof. By signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent and release form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. 

 

I hereby release, Michael K. Sedgewick, EAMP from any and all liability relating to the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care.

 

I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. 

 

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Michael K. Sedgewick, EAMP, regarding any cure or improvement of my condition.

 

Printed Name of Patient:__________________________________________________

 

Signature: ______________________________________________ Date:__________ 

 

PARENT OR GUARDIAN OF A MINOR: I, as parent or guardian of the below named minor, hereby give my permission for this child or ward to participate as a patient in the above named treatment(s), and further agree, individually and on behalf of this child or ward, to the terms as outlined herein.

 

Parent / Guardian printed name and signature for participants under 18:

 

Name:__________________________________________________________

 

Signature: _____________________________________________ Date:___________