I voluntarily consent to acupuncture and and other therapies within the scope of Traditional Chinese Medicine performed by Jami R. Rose, OMD.

My treatment may include, when clinically appropriate, acupuncture, electroacupuncture, moxibustion, infrared heat therapy, cupping, gua sha (scraping), Tui Na (Chinese therapeutic massage/acupressure), lifestyle counseling, nutritional guidance, and recommendations for dietary supplements or Chinese herbal medicine.

I understand that acupuncture and related therapies are generally considered safe when performed by a licensed practitioner. Possible side effects may include temporary soreness, minor bleeding, bruising, numbness or tingling, lightheadedness, fatigue, or a temporary increase in symptoms before improvement.

I understand that cupping therapy produces temporary circular discoloration or bruising, and that gua sha produces temporary redness, petechiae (small red or purple spots), or bruising. These are expected treatment responses and typically resolve within several days or weeks. Less common side effects of these therapies include temporary soreness, blistering, skin irritation, or rarely, skin infection.

If dietary supplements or Chinese herbal medicine are recommended as part of my treatment plan, I understand that these products are intended to complement—not replace—appropriate medical care. I understand that even natural products may cause side effects, allergic reactions, or interactions with prescription medications, over-the-counter medications, or other supplements. I agree to inform my practitioner of all medications, supplements, allergies, pregnancy status, and significant medical conditions so recommendations can be made safely. I will follow the recommended directions for use and notify my practitioner if I experience any unexpected or adverse effects.

I understand that no guarantees or assurances have been made regarding the outcome of treatment and that individual responses vary.

I understand that acupuncture and Traditional Chinese Medicine are intended to complement—not replace—appropriate medical care. I remain responsible for obtaining evaluation and treatment from my physician or other qualified healthcare provider when appropriate.

I certify that the information I have provided regarding my health history is accurate and complete to the best of my knowledge, and I agree to notify my practitioner of any significant changes in my health, medications, or pregnancy status.

I understand that I may ask questions about my treatment at any time and am free to decline or discontinue treatment at any point.

By signing below, I acknowledge that I have read and understood this informed consent, have had an opportunity to ask questions, and voluntarily consent to receive treatment from Jami R. Rose, OMD. Unless I withdraw my consent, this authorization shall remain in effect for my current condition and any future treatment provided by this clinic.