Please read carefully
Informed Consent for Care
I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary including; needling, moxibustion, cupping, guasha, laser acupuncture, electro acupuncture and other techniques such as Reiki and Emotional Polarity Technique. These procedures may be performed by the practitioner (Vanessa Groshong), and/or anyone working in this clinic authorized by the practitioner listed above.
I have had the opportunity to discuss with the practitioner and/or with other office or clinic personnel the nature and purpose of acupuncture care and other procedures. I understand that the results are not guaranteed.
I further understand and am informed that, as in all health care, in the practice of acupuncture, even though all needles are pre-sterilized and disposable there are some risks to treatment including, but not limited to: soreness, bruising, blistering, mood fluctuation, nausea, fainting, and bleeding. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the procedures which the practitioner feels at the time based upon facts then known, are in my best interest.
I have read the above consent. I have also had an opportunity to ask questions about its content, and by signing digitally, I agree to the above named procedure(s). I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
Doctor/Patient Consultation
Section 8(1) of Alberta’s Acupuncture Regulation stipulates that an acupuncturist shall not undertake the care 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.
Acupuncturist: Vanessa Groshong
Business Address: 4825 89st, Edmonton, AB T6E 5K1
