Please read this information carefully, and ask if there is anything that you do not understand.
While acupuncture, Chinese Medicine, registered massage therapy, and other treatments provided by Yinstill Reproductive Wellness have proven to be highly effective in correcting conditions and maintaining overall well-being, practitioners are required to advise patients that there may be some risks. Although practitioners cannot anticipate all the possible risks and complications that may arise with each individual case, you should be aware that the following side effects can occur. If there are particular risks that apply in your case, your practitioner will discuss these with you.
By clicking ‘Yes’ it means I understand that I will have an opportunity to discuss with the acupuncturist or massage therapist and/or with other office or clinic personnel, the nature of massage therapy treatment and other procedures. I understand the results may not be guaranteed. I understand that I will be draped at all times and the areas undraped will be secure to insure there is no indecent exposure. If undraping my gluteals is significant in the treatment I do understand that it is part of the therapy.
What are the possible side effects of acupuncture?
• Drowsiness can occur in a small number of patients, and if affected, you are advised not to drive;
• Minor bleeding or bruising can occur from acupuncture;
• In less than 3% of patients, symptoms may become worse before they improve for 1-2 days following treatment. This is usually a good sign. Please advise your acupuncturist if worsening of symptoms continues for more than 2 days;
• Fainting can occur in certain patients, particularly at the first treatment;
What are the possible side effects of Chinese Medicine and other treatments provided at this clinic?
• Bruising (looks like a circular hickey) is a common side effect of cupping
• Pneumothorax (collapse of a lung) is possible if practitioner actually penetrate the lung organ.
• Minor burn blisters may occur due to moxibustion therapy
• The herbs and nutritional supplements from plant, animal and mineral sources that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses or inappropriate during pregnancy.
What are the possible side effects of massage therapy?
By clicking ‘Yes’ it means I am informed that, as in all health care, in the practice of massage therapy there are some very slight risks to treatment, including, but not limited to, muscle strains and sprains, bruising, light headed or dizziness, and tenderness. I do not expect the massage therapist to be able to anticipate and explain all risks and complications and I wish to rely on the massage therapist to exercise judgment during the course of the treatment which the massage therapist feels at the time, based upon the facts then known, and is in my best interests. I am informed that I have the right to alter the therapist’s pressure during the massage treatment.
Is there anything your practitioner needs to know?
Apart from the usual medical details, it is important that you let your practitioner know:
• If you have ever experienced a fit, faint, or other odd detached sensations;
• If you have a pacemaker or any other electrical implants;
• If you are pregnant;
• If you have a bleeding disorder;
• If you are taking anti-coagulants (blood thinners) or any other medication;
• If you have damaged heart valves or have any other particular risk of infection.
• If you have not eaten in the last few hours.
Statement of Consent
I confirm that I have read and understood the above information, and I consent to having treatments and procedures from Yinstill Reproductive Wellness. I have read the possible risks of treatment outlined above, but do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment. I also understand that I can refuse treatment at any time. I wish to rely on my practitioner to exercise judgment during the course of treatment which, based upon the facts then known, is in my best interests. I understand the practitioner may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily agreeing to the statements on this page I show that I have read this consent to treatment, have been told about the risks and benefits of treatments provided by Yinstill Reproductive Wellness, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment.
The information received and collected about our clients/patients from their visit to Yinstill Reproductive Wellness is strictly private and confidential. It is used and viewed only by the healthcare professionals and staff employed by Yinstill Reproductive Wellness, unless, in the best interest of the client/patient, a practitioner determines that there is a need to communicate with another person or healthcare professional outside of Yinstill Reproductive Wellness (also, Yinstill Reproductive Wellness will not give, share, sell, or transfer any personal information to a third party unless required by law). Under absolutely no circumstances would this communication happen without the signed consent of the client/patient. The client/patient information will be stored both in digital and hard copy format on Yinstill Reproductive Wellness premises. On occasion, Yinstill Reproductive Wellness may use client/patient information to conduct clinical studies to help us improve upon services provided.
If you are going to be more than 15 minutes late, please call to confirm availability. A 24 hour notice for cancelled or rescheduled appointments is necessary in order to avoid the cancellation fee (full fee). This allows us time to schedule another patient that would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and respect for our time and yours.
Patient information release form
I, the patient of Yinstill Reproductive Wellness, give full consent so that Yinstill Reproductive Wellness may consult freely with other physicians and healthcare professionals (of which whose care I am under) regarding any of my medical treatments or relevant information. This could include the exchange of both verbal and written communications (including lab work).