Acupuncture Clinic XYZ 338, Carson City, Nevada

Consent Form

Informed consent form for___________________________.

[Name of Principle Investigator].

Personal Information of the Patient

Address: _________________________.

Telephone no: __________________________.

Any previous illness or medical conditions Detail: _________________.

Name of the previous physician if any________________________________.

Insurance no. __________________________________.

At our Acupuncture Clinic 338, Carson City, Nevada, we provide quality acupuncture therapy in compliance with state’s law and regulation. The first time examination fee will be $145, and further will be charged depending upon the nature of the treatment. Following are the reasons, benefits, risk, and statement of patient’s rights and responsibilities concerning acupuncture treatment at our clinic.

The Reasons for Acupuncture treatment

Acupuncture is an effective therapy for patients with several conditions such as side effects of cancer treatment, i.e., nausea caused by the chemotherapy. Also, it strengthens the immune system, eases the pain, improves energy level, relieves headaches, migraines, back pain, improves fertility in women, and treats asthma, sports injuries, chronic fatigue problems, and gastrointestinal disorders. The treatment is carried out through the insertion of fine, sterilized needle into the skin. To further enhance the effects pressure or electric stimulation are used.

Benefits of Acupuncture treatment

The primary advantage of acupuncture therapy is that it increases and restores the balance of energy in the body. Further, it caters different types of emotional disorders and relieves back pain, headache, migraines, joint ache, muscle pain, neck stiffness, etc. Acupuncture serves as a rehabilitation tool for the patients who have suffered a stroke and neurological disorders. It is an effective way of treatment for respiratory conditions such as asthma and other related issues. Moreover, it has proved beneficial to overcome addiction, thus improving the overall well-being of an individual.

Risks of Acupuncture therapy

Some patients after receiving acupuncture therapy report slight soreness for some time. Also, acupuncture is harmful to the patients with bleeding disorders, those who take blood thinners. In many cases, acupuncture is not the cure for the physical disease and so is the case with a broken bone, though it helps to diminish the pain. Also, it may not be a one-off treatment; instead it requires follow up procedures with a proper schedule. However, the acupuncture therapy has almost no side effect.

Statement of Patients’ Rights and Responsibilities

At our Acupuncture Clinic XYZ 338, Carson City, Nevada, we have embraced following policies regarding rights and responsibilities of all the patients.

1. Patients have legal right to receive treatment honorably and adequately
2. Parents are fully protected from any discrimination or rude behavior according to their rights; discrimination is the violation of the law. In compliance with anti-discrimination laws and practices, patients are entitled to all the benefits else be discriminated against on the bases of color, race, origin or on the grounds of physical or mental condition or age in admission, taking part or receiving services and advantages with respect to any programs according to the provisions in Title VI of the Civil Rights Act of 1964, section 504 about the Rehabilitation Act of 1973 and all the rules and regulations of the U.S that protect the fundamental rights of individual concerning their health and services. In this regard, all the relevant sections of Federal regulations also apply.
3. Patient’s data regarding their health and mental conditions as well as their personal information will be protected, and privacy will be maintained.
4. Patients will have the right to receive full updates about their situation and express their concerns accordingly.
5. Patients will have the provision to leave the medical treatment even if it’s against the advice.
6. A patient will have the right to receive the details of their bills irrespective of the mode of the payment they are choosing.
7. They have the right to know about the charges of any particular treatment.
8. Patients have the right to know about the after treatment care and service if required considering their medical condition.
9. A patient should be accompanied by an adult if he/she is a minor
10. Patients have the right to receive treatment or advice in the safe setting free from any abuse or pressure.
11. It is the legal right of the patient to give their advice any feedback for improvement of healthcare services.
12. Patient has the right to ask for a prior adjustment in a particular case, and the clinic will look into patient’s request.
13. It is the responsibility of the patient to provide correct information as it is necessary to receive appropriate treatment.
14. The patient should not be rude and harsh to any of the staff members at the clinic.
15. It is the responsibility of the patient to get an appointment before attending the clinic.
16. After getting appointment patient should come in time to avoid the hassle.
17. The customer should pay the consultation fee before the process of examination as per the policy of the clinic.
18. In case of any complaints about any of the staff members, the patient should directly report to the physician so that necessary action can be taken.
19. The patient should not involve in any fight with any of the staff member. It is the responsibility of the patient to obey all the rules and regulations so that a better and peaceful environment of cooperation can be created.

I have thoroughly read the information and I fully understand the procedures, reasons, benefits, and risk of this treatment. Also, I am completely aware of the statements of patient’s rights and responsibilities. Other relevant details have also been brought to my notice. Therefore, I give my consent to be examined/for examination of my dependent and receive this treatment.

Name of the Patient/Guardian (If less than 18 years) __________________.

Signature of the Patient/ Guardian________________.