{"id":614,"date":"2025-10-25T22:36:05","date_gmt":"2025-10-26T02:36:05","guid":{"rendered":"https:\/\/rmtandrac.com\/therapist\/?page_id=614"},"modified":"2025-10-25T22:50:40","modified_gmt":"2025-10-26T02:50:40","slug":"consent-for-acupuncture","status":"publish","type":"page","link":"https:\/\/rmtandrac.com\/therapist\/consent-for-acupuncture\/","title":{"rendered":"Consent for Acupuncture"},"content":{"rendered":"<style id=\"wpforms-css-vars-584-block-ce3f0b47-a1dd-4baf-bd9c-2f11cfdcccf7\">\n\t\t\t\t#wpforms-584.wpforms-block-ce3f0b47-a1dd-4baf-bd9c-2f11cfdcccf7 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-ce3f0b47-a1dd-4baf-bd9c-2f11cfdcccf7 wpforms-render-modern\" id=\"wpforms-584\"><form id=\"wpforms-form-584\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"584\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/therapist\/wp-json\/wp\/v2\/pages\/614\" data-token=\"35258e52af9e5adfd2f25703c3a89d9c\" data-token-time=\"1776621793\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-584-field_1-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"1\"><div id=\"wpforms-584-field_1\" aria-errormessage=\"wpforms-584-field_1-error\"><h1> Patient Informed Consent to Treatment <\/h1><h1><\/h1><\/div><\/div><div id=\"wpforms-584-field_2-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"2\"><div id=\"wpforms-584-field_2\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-584-field_2-error\"><p><b>I, or the person listed below, have discussed with my Traditional Chinese Medicine or Acupuncturist the specifics of my assessment or treatment and understand nature, risks and reasons for this procedure. I voluntarily consent to Traditional Chinese Medicine\/Acupuncture and understand that I may withdraw my consent and halt my participation at any time.<\/b><\/p>\n<ol>\n<li>I understand that some of the techniques used under the scope of Traditional Chinese Medicine include the use of sterile, single-use needles to penetrate the skin. Additional treatment methods can include, but are not limited to: acupuncture, acupressure, the electrical stimulation of needles, cupping or moxibustion, gua sha, and tuina. Before any of these procedures are performed, my practitioner will discuss my treatment options and only processed if my consent is given.<\/li>\n<\/ol>\n<ol start=\"2\">\n<li>My practitioner has informed me the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.<\/li>\n<\/ol>\n<ol start=\"3\">\n<li>I will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.<\/li>\n<\/ol>\n<ol start=\"4\">\n<li>I understand that I must let my practitioner know I am carrying, or believe to have any infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.<\/li>\n<\/ol>\n<ol start=\"5\">\n<li>I understand that there are no guarantees for the results of my treatment. Traditional Chinese Medicine does not often provide an instant cure. The length of my treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin to improve.<\/li>\n<\/ol>\n<ol start=\"6\">\n<li>I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered.<\/li>\n<\/ol>\n<ol start=\"7\">\n<li>I discuss the content of this form with my practitioner. I acknowledge that I can ask any questions I may have and receive answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.<\/li>\n<\/ol>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div>\t\t<div id=\"wpforms-584-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-584-field_7\" >Signature: Practitioner Name:<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-584-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-584-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-584-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-584-field_4\">Patient Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-584-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-584-field_4-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-584-field_5-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-584-field_5\">Patient Signature: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-584-field_5\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][5]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-584-field_5-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-584-field_5-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-584-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-584-field_6\">Date  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-584-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-584-field_6-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-584-field_19-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-584-field_19\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-584-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" spellcheck=\"false\" aria-errormessage=\"wpforms-584-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div><div id=\"wpforms-584-field_18-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Practitioner Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-584-field_18\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][18][first]\" aria-errormessage=\"wpforms-584-field_18-error\" required><label for=\"wpforms-584-field_18\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-584-field_18-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][18][last]\" aria-errormessage=\"wpforms-584-field_18-last-error\" required><label for=\"wpforms-584-field_18-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-584-field_12-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"12\"><div id=\"wpforms-584-field_12\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-584-field_12-error\"><p><i>By signing this form, I acknowledge that I have reviewed the form with the patient (or substitute decision-maker) and have answered the patient\u2019s (or substitute decision-maker\u2019s) questions.<\/i><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-584-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-584-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-584-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"584\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/rmtandrac.com\/therapist\/wp-json\/wp\/v2\/pages\/614\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-584\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/rmtandrac.com\/therapist\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container 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