PATIENT INFORMATION AND CONSENT FORM

Kelsey Healing Arts
107 Pilgrim Village Dr., Ste 200
Cumming, GA 30040

WHAT IS ACUPUNCTURE?
Acupuncture is a form of therapy in which fine needles are inserted into specific points on the body.
WHAT IS THE ROLE OF ACUPUNCTURIST IN GEORGIA?
The Georgia Code 360-6-.16 states that an acupuncturist is not licensed to practice medicine in the
State of Georgia. Accordingly, an acupuncturist is not able to make a medical diagnosis of the
person’s disease. Therefore, if you are seeking to obtain a medical diagnosis, then you should see a
licensed physician and seek medical advice from a licensed physician.
DOES ACUPUNCTURE HAVE SIDE EFFECTS?
Acupuncture is generally very safe.

  • Serious side effects are rare – less than one per 10,000 treatments
  • Drowsiness occurs after treatment in a small number of patients
  • Minor bleeding or bruising occurs after acupuncture in about 3% of treatments.
  • Pain during treatment occurs in about 1% of treatments.
  • Symptoms can get worse after treatment (less than 3% of patients). You should tell your
    acupuncturist about this, but it is usually a good sign.
  • Fainting can occur in certain patients, particularly at the first treatment.
    In addition, if there are particular risks that apply in your case, your practitioner will discuss these with
    you.
    IS THERE ANYTHING YOUR PRACTITIONER NEEDS TO KNOW?
  • If you have ever experienced a seizure, dizziness, or fainting episode
  • If you have a pacemaker or any other electrical implants
  • If you have a bleeding disorder
  • If you are taking anti-coagulants or any other medications
  • If you have damaged heart valves or have any other particular risk of infection
    SINGLE-USE, STERILE, DISPOSABLE NEEDLES ARE USED BY ACUPUNCTURISTS.
    STATEMENT OF CONSENT
    I am seeking to be treated with acupuncture for the condition of _________. I confirm
    that I have read and understood the above information and I consent to having acupuncture treatment.
    I understand that I can refuse treatment at any time.

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