PARENT/GUARDIAN CONSENT FORM FOR ACUPUNCTURE TREATMENT

Patient Information:

Child’s Full Name:

Date of Birth

Parent/Guardian Name:

Relationship to Child:

Contact Information (Phone):

Practitioner Information:

Practitioner’s Name

Qualifications

Registration Number

Clinic Name

Clinic Address

Phone Number

1. Purpose and Nature of Treatment

I understand that the purpose of acupuncture treatment is to address my child’s health concerns. Acupuncture involves the insertion of fine needles into specific points on the body to promote healing and balance. The proposed treatment plan will be discussed with me, and I acknowledge that acupuncture may be used as part of an integrative approach to my child’s care.

2. Explanation of Risks and Benefits

I have been informed of the possible benefits and potential risks of acupuncture treatment, which may include but are not limited to:

Benefits: Improvement in symptoms, pain relief, enhanced well-being.
Risks: Mild bruising, soreness, dizziness, fainting, or minor bleeding at needle sites.

I have been advised that while acupuncture is generally safe, there are some risks involved, and that I should report any concerns or adverse reactions during or after treatment.

3. Alternatives to Acupuncture

I understand that alternatives to acupuncture may be available, including conventional medical treatments and other complementary therapies. I have discussed these alternatives with the practitioner and have been informed of the potential benefits and risks of these options.

4. Confidentiality

I understand that my child’s medical information and treatment records will be kept confidential according to legal and ethical requirements. However, I am also aware that the practitioner may need to share information with other health professionals involved in my child’s care, and there are circumstances where the practitioner may need to disclose information in cases of emergency or when required by law.

5. Consent to Treatment

I, the undersigned, give my consent for the practitioner named above to provide acupuncture treatment for my child, [Child's Name], as outlined in the treatment plan. I understand that I may withdraw my consent at any time, and the treatment will cease immediately.

6. Emergency Procedures

I have been informed of the emergency procedures in place at this clinic and know what steps to take should my child experience an adverse reaction or health issue during the acupuncture session.

7. Parent/Guardian Rights

I understand that as the parent or legal guardian, I have the right to refuse or withdraw consent for my child’s acupuncture treatment at any time, without affecting my child’s right to other medical care or services.

Consent Acknowledgement

I confirm that I have had the opportunity to ask questions about the treatment and that these questions have been answered to my satisfaction. I am aware of the nature of acupuncture, the potential risks and benefits, and the alternative treatments available.

I give my consent for acupuncture treatment to be provided to my child, and I understand that my child will be treated in accordance with the ethical and professional standards outlined by the acupuncture practitioner and relevant regulatory bodies.

Parent/Guardian Name

Signature

Date

Witness Information

Witness Name

Witness Signature

Date

Your submission has been received.

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