INFORMED CONSENT AND DISCLOSURE

INFORMED CONSENT:

I hereby request and consent to acupuncture treatment and/or herbal supplement recommendations for me (or my legal charge) provided by Yin-Jia (Rose) Gong, MD. I understand that Dr. Gong to exercise judgment during the course of the procedure and determines is in my best interests. I may request another person of my choice to be present in the treatment room during treatment.

Dr. Gong has discussed with me the procedures listed below that may be used in my treatment. I have read the information below and understand the possible risk involved. I agree to Dr. Gong’s use of this treatment (if indicated).

- Acupuncture is a safe and effective method of treatment. However, it can occasionally cause slight bleeding that usually resolves with pressing dry cotton on the spot where the skin is bleeding. It is also normal for the patient to have a temporary warm, tight, sore or tingling sensation at the acupuncture site.

- Acupressure/TuiNa involves rubbing, kneading, pressing, and stroking, etc., which may result in muscle soreness at the massage site that can last several days. This technique may require disrobing. I understand all attempts will be made to assure my privacy.

- Indirect Moxibustion requires burning an herbal material near the skin or on an acupuncture needle. Every precaution is taken to prevent skin contact, but the possibility of skin contact and mild burns exists.

- Cupping involves a localized suction produced by heating a small glass cup. There is a possibility of local bruising from the suction and slight burning or blistering due to the heat involved in the technique.

- Gua Sha involves scraping over a small area by using a smooth-edged instrument. There is a possibility that local bruising is likely to occur at the site where the Gua Sha is performed.

- Tapping, Plum Blossom, Bleeding, Pricking all involve multiple needle pricks at a localized site. Slight bleeding and/or bruising at the treatment site is a likely occurrence. Only single-use needles are used in these procedures.

- Electrical Stimulation/TENS uses microcurrent electricity to stimulate acupuncture points. A mild tingling light sensation of electricity will be felt.

- Treatment Using Control Points Ren 1/Du1. In very rare cases, the Acupuncture Provider may recommend treatment using acupuncture points near the genital organs. If this is necessary, the Acupuncture Provider will notify me and will provide alternative treatments if I am uncomfortable with treatment using these points. I understand all attempts will be made to assure my privacy.

I have read, or have had read to me, the above consent, and have had the opportunity to ask questions and discuss this with Dr. Gong. I consent to the treatment that involves the above procedures for my present condition(s) and any future conditions. I have the right to refuse or discontinue any treatment at any time and understand that this refusal may affect the expected results.

Authorization for Release of Medical Information: I further understand that Dr. Gong’s office may need to contact my medical physician when my condition needs to be co-managed with my medical doctors. The conditions that may require co-management include but are not limited to; pregnancy related nausea, pain associated with Multiple Sclerosis, neuromusculoskeletal effects of stroke, pain/nausea related to cancer/tumor, chemotherapy related nausea, pain/nausea related to AIDS/ARC, pain or nausea related to surgery. This coordination of care intends to manage my health condition in my best interest and assure the optimal outcome of my acupuncture treatments. Therefore, I give my authorization to Dr. Gong’s office to contact my medical physician if/when necessary.

_________________________________________ ______________________________________

Patient name (please print) Patient Signature

________________________________________

Primary Care Physician (or specialist) Name

_________________________________________ ______________________________________

Primary Care (or specialist) Telephone Date