Accuracy of Information:
I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.
Privacy & Sharing of Information:
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. in addition, I authorize for my personal and medical information to be shared between the attending Registered Acupuncturist and Urban Massage & Wellness to provide seamless and streamlined care; such information will be kept confidential by all parties in accordance with applicable legislation.
Declaration of Medical Consultation:
Section 8(1) of Alberta’s Acupuncture Regulation stipulates that an acupuncturist shall not undertake the care and treatment of a person unless:
a) that person has already consulted with a physician or, in the case of dental pathology, a dentist about the condition for which care and treatment from the acupuncturist is being sought;
(b) that person has informed the acupuncturist that a physician or dentist has been consulted about the condition; and
(c) the acupuncturist has completed a patient consultation form.
-I have consulted with a physician or dentist (as appropriate) about the condition for which acupuncture treatment is now being sought.
Consent to Treatment Modalities:
Traditional Chinese Medicine utilizes a wide range of modalities to tap into the body’s natural, innate ability to heal to re-establish a balanced state of wellbeing. These classical techniques have endured the test of time, and include acupuncture, cupping, Gua-Sha friction technique, Tui-Na massage and acupressure, and moxibustion, or any combinations thereof. Acupuncture The use of hair-thin, sterile, one-time use disposable needles to promote the body’s natural healing response by inserting them into known acupuncture points. Occasionally, this may produce strong stimulative effects including mild soreness or throbbing, but should not be painful. From time to time, a minute electrical current may be added, producing a very mild tingling sensation.
Cupping
A negative-pressure technique performed over the skin to increase blood flow to the affected area, thereby enhancing the cellular regenerative processes of the body.
Gua-Sha
A friction technique over muscular tissue to draw stagnant blood out from the capillaries to just beneath the surface of the skin. Light bruising over the affected area is a normal and desired result.
Tui-Na Massage and Acupressure
Hands-on manipulation of muscular tissue and acupuncture points. Many of the Tui-Na massage techniques share a common or similar origin as Swedish massage therapy. Muscles are often loosened and relaxed when performed in conjunction with acupuncture.
Moxibustion
An application of heat therapy; this can be achieved through many different ways: mainly, topical application of herbs and infrared light therapy. The underlying therapeutic principle is not dissimilar to the use of a hot water bottle or a hot compress over a small area.
The use of any, or a combination, of the modalities may occasionally produce side effects such as light temporary bruising, bleeding, swelling, numbness/tingling, or soreness over the affected areas of the body; and, such effects may persist up to 48 hours after treatment. In extreme, but very rare, instances, needle stick injuries including bent/stuck needles, infection, nerve injury, pneumothorax, or perforation of the peritoneum, may occur.
Furthermore, in pregnant women, Traditional Chinese Medicine modalities can have both positive and negative impacts on the fetus(es) in utero. For example: Positively, specific acupuncture points can help in instances of a breeched baby; negatively, certain acupuncture points are known to induce labour. In order to take the necessary precautions, the attending acupuncturist must be informed of all pregnancy or any possibility thereof.
-I understand the risks associated with the modalities of Traditional Chinese Medicine, and agree to indemnify the attending acupuncturist(s) from all unintended effects.