Acupuncture Consent Form

Diagnosis and Treatment Consent

I, the undersigned, do hereby give my voluntary consent for administering medical acupuncture to my pet. I understand that acupuncture is considered an alternative therapy in veterinary medicine. Ancillary techniques of acupuncture may be used, including one or more of the following: electroacupuncture, moxibustion, laser therapy, and aquapuncture. I understand that other relevant diagnostics and therapies may also be required to diagnose and treat my pet. Acupuncture has been explained to me as a medical treatment performed by the insertion of sterile (single-use) acupuncture needles through the skin into the underlying tissues and muscles at specific points on the body for the purpose of alleviating pain and/or for treating other clinical conditions. I understand that a minimum of 5-6 treatments is often needed before a response to therapy can be reasonably expected.

Acupuncture is considered to be extremely safe. Possible side effects of acupuncture, which can occur at any time during the course of therapy, have been explained to me and include the following: bleeding; possible temporary worsening of symptoms; bruising, redness, swelling, or soreness at the treated sites; transient weakness or lethargy post-treatment.

I state that my pet does not have any of the following:
- Pregnancy
- Bleeding disorder (e.g. vonWillebrand’s disease, hemophilia, immune-mediated thrombocytopenia)
- Pacemaker
- Local infection (skin infection, abscess, etc)

I have been informed of the conventional treatments available and their probable ability to cure my pet’s condition. I state that my pet has been evaluated by a veterinarian for the condition(s) being treated with acupuncture.