INFORMED CONSENT FORM FOR ACUPUNCTURE TREATMENT OF MINORS
Patient Information:
Practitioner Information:
1. Purpose of Treatment
I, the undersigned, understand that my child is being treated with acupuncture as part of a holistic treatment plan to address specific health concerns. Acupuncture involves the insertion of thin needles into particular points on the body with the aim of improving energy flow, relieving symptoms, and supporting the body’s natural healing processes.
The purpose of acupuncture treatment will be to address my child’s specific condition(s), which have been discussed with me by the acupuncturist.
2. Nature of Treatment
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Acupuncture involves inserting fine, sterile needles into specific points on the body. These points are chosen based on my child’s condition and treatment goals.
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My child’s first acupuncture session will involve an initial assessment, where the acupuncturist will review medical history, conduct a physical examination, and discuss the treatment plan.
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Subsequent sessions will consist of needle insertions based on the treatment plan agreed upon.
3. Risks and Potential Side Effects
I have been informed of the following possible risks and side effects associated with acupuncture:
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Common, Mild Side Effects: Minor bruising, slight soreness, or redness at the needle sites, dizziness, fatigue.
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Less Common Side Effects: Nausea, fainting, or minor bleeding at the needle site.
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Rare but Serious Reactions: Infections (due to non-sterile needles), punctured organs (rare), and nerve damage (extremely rare).
I understand that although these risks are rare, I should immediately inform the practitioner if my child experiences any adverse effects.
4. Benefits
I understand that acupuncture has been shown to provide a range of benefits, including:
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Pain relief (e.g., for headaches, back pain)
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Stress reduction
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Improved circulation
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Support for digestive issues, immune function, and other specific conditions
While acupuncture may be effective for many conditions, results may vary. The practitioner has explained that there are no guarantees regarding outcomes, as individual responses to acupuncture can differ.
5. Alternatives to Acupuncture
I have been informed of the following alternative treatments to acupuncture:
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Traditional medical treatments (e.g., medication, physical therapy)
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Other complementary therapies (e.g., herbal medicine, chiropractic care, massage therapy)
I understand that I can choose any of these alternatives, and I have been given an opportunity to ask the acupuncturist about them.
6. Confidentiality
I understand that my child’s health information will be kept confidential in accordance with privacy laws and regulations. The acupuncturist will not share my child’s personal information or treatment details without my consent, except where required by law or in cases of medical emergencies.
7. Consent to Treatment
By signing below, I confirm that:
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I have been provided with sufficient information regarding acupuncture and have had the opportunity to ask questions.
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I understand the nature of the proposed treatment, its potential risks and benefits, and available alternatives.
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I consent to acupuncture treatment for my child, [Child’s Name], and I authorize the practitioner to proceed with the treatment as outlined above.
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I understand that I can withdraw my consent at any time without affecting my child’s access to other medical care.
7. Consent to Treatment
By signing below, I confirm that:
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I have been provided with sufficient information regarding acupuncture and have had the opportunity to ask questions.
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I understand the nature of the proposed treatment, its potential risks and benefits, and available alternatives.
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I consent to acupuncture treatment for my child, [Child’s Name], and I authorize the practitioner to proceed with the treatment as outlined above.
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I understand that I can withdraw my consent at any time without affecting my child’s access to other medical care.
8. Emergency Protocols
In the event of an emergency, I understand that the practitioner will follow standard emergency protocols. In case my child has any adverse reactions, I will immediately contact the practitioner or seek emergency medical care if necessary.
9. Parent/Guardian Rights
I understand that as the parent or guardian, I have the right to withdraw consent for acupuncture treatment at any time. I am aware that my child’s treatment will cease immediately if I choose to do so.
Consent Acknowledgement
I confirm that I have read and understood this informed consent form. I acknowledge that I have been provided with all the necessary information regarding acupuncture treatment for my child, including the risks, benefits, and alternatives.
Witness Information
Clinic/Practitioner Acknowledgement
I, the undersigned practitioner, confirm that I have explained the treatment, risks, benefits, and alternatives to the parent/guardian of the child, and that they have had the opportunity to ask questions.
Important Notes:
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The signed consent form should be kept in the patient’s medical record.
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Ensure that the parent or guardian has ample time to review the form, ask questions, and provide consent before treatment begins.
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Always explain each step of the treatment plan thoroughly.
Your submission has been received.
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