INFORMED CONSENT FOR ACUPUNCTURE

ACUPUNCTURE INFORMED CONSENT TO TREATI hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.I understand that methods of treatment may include, but are not limited to, acupuncture, Moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of Moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during treatment, which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.By voluntarily 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 form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
ACUPUNCTURIST NAMES:    
Dr. Sabrina Jhorna (Dr. Jhorna),                                                    
Dr. Rungradith Mingpatumkij (Dr. Ming)    
Patient Name (PRINT): ______________________
Patient Signature:  ______________________
Date ______________________
(Or Patient Representative) (Indicate relationship if signing for patient)____________________
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Notice of Privacy Practices for Regulations HIPPA
In order to receive adequate treatment, Complete Wellness NYC originates and maintains health records describing health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care of treatment.Additionally, following HIPPA regulations, the center maintains the privacy of all health information in accordance with state and federal law.Matters regarding your care will be kept confidential except in the following circumstances: you sign a release of information giving permission to release Information to a specific individual or agency; child abuse patient is in imminent danger to self or others, subpoena of records.I ascertain that I have read, or had someone read to me, the Notice of Privacy Practices for HIPPA Regulations and that a written copy of the Complete Wellness NYC Notice of Privacy Policy is available upon request.
Patient Signature: ______________________
Date: ____________________________
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WE, THE UNDERSIGNED, DO AFFIRM THAT (THE PATIENT) HAS BEEN ADVISED BY, (A LICENSED ACUPUNCTURIST), TO CONSULT A PHYSICIAN REGARDING THE CONDITION OR CONDITIONS FOR WHICH SUCH PATIENT SEEKS ACUPUNCTURE TREATMENT.
Patient Signature ______________________
Date _____________________

Dr. Sabrina Jhorna (Dr. Jhorna)
Signature  ______________________
Date _____________________


Dr. Rungradith Mingpatumkij(Dr. Ming)
Signature  ______________________
Date _____________________

INFORMED CONSENT FOR CHIROPRACTIC

As with any healthcare procedure, I understand that there are certain
complications, which may arise during chiropractic manipulation, and that those complications include: fractures,
disc injuries, dislocations, muscle strain, Homer's syndrome, diaphragmatic paralysis, cervical myelopathy and
costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to
the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel
some stiffness and soreness following the first few days of treatment. I understand that fractures are rare
occurrences and generally result from some underlying weakness of the bone. I also understand that stroke and
other complications are also generally described as "rare."
I have been advised that x-rays can be hazardous to an unborn child. To the best of my knowledge, I am
not pregnant.
I understand that other treatment options for my condition may include: Self-
administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories,
muscle relaxants and painkillers; hospitalization with traction; and surgery.
Contraindications to Manipulation / Adjustment. I understand that you will not give me an adjustment /
manipulation, x-rays, modalities, or therapies if you feel that such are contraindicated. In the event that the Care
does not include such procedures, I have discussed all contraindications with you and fully understand them.
Patient’s Consent. I have thoroughly discussed and reviewed my recommended Care with you, as well as your
examination, diagnoses, and thoughts regarding my condition, and also all of the information in this Informed
Consent. I have had ample opportunity to explore other potential forms of care, have asked you all of the questions
that I have, and have no additional questions. I voluntarily and knowingly elect to receive the recommended Care.
Patient Name (PRINT): ______________________
Patient Signature:  ______________________
Date ______________________

INFORMED CONSENT FOR PHYSICAL THERAPY

I understand that I am receiving physical therapy for an initial evaluation and/or treatment. This may consist of having any or all of the following: Reviewing my past medical history, a movement assessment, various objective tests & measures such as range of motion and strength, manual therapy, education regarding my plan of care and therapeutic exercise prescription. As with all forms of medical treatment, there are benefits and risks involved with physical therapy. As patient responses to a specific form of treatment can vary widely from patient to patient, it is not always possible to predict responses to a specific form of treatment. Therefore, Complete Wellness Medical P.C. cannot guarantee any reaction or success to a given form of treatment. There is also a risk that your treatment may result in pain, injury, or may aggregative a previous condition. I may also discuss with my physical therapist the potential risks and benefits of a specific treatment and possible alternative treatments. I can stop evaluation and treatment at any time and am freely able to ask my physical therapist questions at any time during the evaluation/treatment session.
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Patient Name (PRINT): ______________________
Patient Signature:  ______________________
Date ______________________

INFORMED CONSENT FOR INFRARED LASER THERAPY

Laser therapy is a safe and effective therapy that is FDA cleared for the temporary relief of pain and reduction of
symptoms associated with mild arthritis and muscle pain. Laser also promotes relaxation of muscle spasm and
promotes vasodilation. Adverse effects from laser therapy are normally rare and temporary.
Pain relief from laser therapy may be dramatic and substantial, lasting for hours, days or weeks. However, your
results may be minimal or insignificant. Adverse effects of laser therapy may occur from multiple causes includinghypersensitivity, preexisting health conditions, thermal effects, excessive pressure from the probe, and laser over-
stimulation. Laser light can damage the retina in your eye. Always wear the laser protective glasses provided.The most common adverse effects are:
1. Temporary increase in pain during application of laser.
2. Temporary increase in pain the following day after laser therapy.
3. Mild bruising from vasodilation or direct pressure of laser tip.
4. Temporary dizziness.
5. Reactions when photosensitizing drugs are used with laser therapy.
I understand the risks of laser therapy and agree to the treatment program outlined by my doctor.
Patient Signature: ________________________________________________________ Date: ________________
Please Print Name: ____________________________________________________________________________
Date of Birth: _________________________________________________________________________________