I consent to acupuncture and other modalities associated with Chinese medicine performed by Jami R. Rose, OMD I have discussed the nature and purpose of my treatment with the licensed acupuncturist, and understand that I am responsible for obtaining primary medical care from my physician, as it is not provided by this clinic.

I understand that methods of treatment may include, but are not limited to acupuncture, electrical stimulation, moxibustion, infra red heat, cupping, gua sha (scraping) tui na (massage and acupressure), herbal medicine, and nutritional counseling. I have been informed that acupuncture is a safe method of treatment, but that side effects may occur including dizziness, fainting, minor bleeding, bruising, numbness, or tingling. While this document describes the major risks and side effects of treatment, I understand that other side effects may occur.

I understand that herbs and supplements are considered safe in the practice of Chinese medicine, and that these products must be prepared and taken according to the instructions and dosages provided. Possible side effects of herbal therapy may include stomachache, gas, nausea, diarrhea, headache or rash. I will notify my practitioner immediately if any adverse effects occur. I further understand that some herbs are inappropriate during pregnancy or when taken with certain pharmaceutical medications, and will notify my practitioner of any possible or actual pregnancy, as well as any changes with my medication.

I understand that treatment is not always successful, and that Jami R. Rose, OMD does not guarantee therapeutic success in association with a specific procedure or series of treatments. I understand that all of my questions regarding treatment will be answered, and I am free to withdraw consent and discontinue treatment at any time.

By signing below I acknowledge that I have read this consent form, have been informed about the possible risks of treatment, 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.