I understand that the treatment modalities performed at the ESATM Student Clinic may include, but are not limited to:

Acupuncture [meaning the practice of Oriental medicine based on traditional Oriental medical theories including but not limited to stimulation of a certain point or points near the surface of the body by the insertion of needles to prevent or to normalize the physiological functions, including pain control, for the treatment of diseases or dysfunctions of the body and includes the techniques of electro-acupuncture, mechanical stimulation, adjunctive therapies and moxibustion]; tui na and other forms of East Asian massage, cupping, gua sha, Oriental Dietary therapy, lifestyle and behavioral education; laser stimulation, thermal methods, magnets, breathing techniques and exercise; and Herbal medicine.

I understand that acupuncture is a generally safe method of treatment with few, but some possible side effects. The potential risks of acupuncture are: slight pain or discomfort at the site of needle insertion, infection, bruises, numbness at the site of needle insertion, weakness, dizziness, fainting, nausea, and the possible exacerbation of problematic systems existing prior to acupuncture treatment. Unusual and infrequent but possible risks of acupuncture include miscarriage, nerve damage, and organ puncture, including pneumothorax (puncture of the lung). Burns and/or scarring are a potential risk of moxibustion or other heat therapies. I understand that while the major risks are described in this document that other possible side effects or risks may occur.

PREGNANCY: I understand that the herbs and nutritional supplements [primarily derived from plant, animal, and mineral sources] that may be recommended and are traditionally considered safe, though some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy or that herbs and/or acupuncture treatment may be limited or denied during pregnancy. Therefore, I will notify the ESATM Student Clinic, clinical supervisor, and interns if there is any possibility that I am or become pregnant. I understand that possible side effects while taking herbs may include, but are not limited to: gas and bloating, epigastric or abdominal discomfort, stomach ache, nausea, vomiting, diarrhea, constipation, skin rashes and/or itchiness, headache ,and tingling of the tongue.

I understand the importance of providing a current and/or updated health history that includes notifying interns of any changes in the following: prescribed medications, over-the-counter medications, herbs, nutritional supplements, etc., that I might be taking or that have been prescribed to me external to the ESATM Student Clinic.

I understand that herbs need to be prepared, consumed, and/or topically applied according to instructions. I understand that some herbs may have an unpleasant aroma or taste. I understand that if my condition were to change [that I suddenly caught a cold or had a fever] to something that was different from the issue for which I was prescribed the formulation, that I should stop taking the preparation and contact the clinic to schedule another appointment for reassessment of my current condition. I will immediately notify a member of the clinic staff of any unanticipated or unpleasant effects associated with the consumption of herbs.

In support of the educational and didactic function of the ESATM Student Clinic, I understand that details of my case may be used for teaching or for research purposes. Publication of any articles or research papers will not include any identifying information.

I am aware that the ESATM student clinic accepts credit and debit cards, checks, and cash as payment for treatment rendered. I am aware and understand that the Intern Clinic of the Eastern School of Acupuncture and Traditional Medicine does not accept Insurance reimbursement as a form of payment and will NOT provide Diagnostic Codes (ICD-9 codes), Procedural Codes (CPT codes), or Practitioner EIN, Tax ID, NPI, or License numbers for insurance claims. Any patient is entitled to receive a receipt upon payment.

It is confirmed that I have had an opportunity to ask questions. It is my intention that this consent form functions to cover the entire course of treatment for any present and future condition/s for which I may seek treatment from the Intern Clinic of the Eastern School of Acupuncture and Traditional Medicine. “I therefore render my consent to the above practices and acknowledge that I understand the aforementioned policies and procedures."