PATIENT ADVISORY TO CONSULT A PHYSICIAN

We are committed to your health and overall wellness.  While acupuncture and other Chinese Medicine modalities have a great deal to offer you as a health care system, they cannot replace the resources available to you through biomedical physicians.  Consequently, we recommend that you consult a physician regarding any condition or conditions for which you are seeking treatment through acupuncture and/or other Chinese Medicine modalities.

To comply with Article 160, section 8211.1 (b) of the New York State Education Law, we request that you read and sign the following statement:

WE, THE UNDERSIGNED, DO AFFIRM THAT (patient) HAS BEEN ADVISED BY (licensed acupuncturist) TO CONSULT A PHYSICIAN REGARDING THE CONDITION OR CONDITIONS FOR WHICH SUCH PATIENT SEEKS ACUPUNCTURE TREATMENT.

II. INFORMED CONSENT & HIPPA CONSENT
I consent to receiving modalities associated with the practice of Traditional Chinese Medicine by Radiant Sun Acupuncture and its affiliates. I have discussed the nature and purpose of these modalities as they pertain to my treatment with the clinician of Radiant Sun Acupuncture named below.

I understand that the modalities associated with the practice of Traditional Chinese Medicine that may be used in my treatment may include, but are not limited to: acupuncture, moxibustion, cupping, Gua Sha, electrical stimulation, Tui Na (Chinese bodywork), Qi Gong, Eastern Dietary Therapy and lifestyle counseling.

I understand that acupuncture is a generally safe method of treatment, but that it may result in some side effects, including, but not limited to, bleeding, bruising, numbness or tingling near the needling sites that may last a few days, as well as dizziness and fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including the puncture of a lung, causing a pneumothorax. While infection is a possible risk, the clinicians of Radiant Sun Acupuncture use sterile, disposable needles and maintain a clean and safe environment. Bruising is a common side effect of Gua Sha and cupping.  Burns and/or scarring are potential risks of moxibustion and cupping.

I do not expect the clinicians of Radiant Sun Acupuncture to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the clinicians of Radiant Sun Acupuncture to exercise judgment during the course of treatment which the clinician(s) think(s) at the time, based upon the facts then known, is in my best interest. I understand that results cannot be guaranteed. I understand that, while this document describes the major risks of treatment through Chinese Medicine modalities, other side effects and risks may occur.

I understand that all of my records will be kept confidential and will not be released to any party without my written consent, in full compliance with HIPAA regulations. My signature below indicates that a written copy of Radiant Sun Acupuncture’s Notice of Privacy Practices has been provided to me. I understand that clinical and administrative staff of Radiant Sun Acupuncture may review my patient records, but all records will be kept confidential and will not be released without my written consent. I also understand that Radiant Sun Acupuncture will, from time to time, send me information via text, mail and/or email including, but not limited to, receipts, newsletters and office announcements, but that my name and contact information will not be released to any other business or organization.

By voluntarily signing below, I show that I have read, or have read to me, the above consent to treatment, have been told about the benefits and risks of the above procedures, and have had an opportunity to ask questions.  I intend this consent form to cover the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek treatment through Radiant Sun Acupuncture.