Prenatal Informed Consent to Treatment

Please read this information carefully, and ask if there is anything that you do not understand.

While acupuncture, Chinese Medicine, naturopathic medical treatments, and other treatments provided by Yinstill Reproductive Wellness have proven to be highly effective in correcting conditions and maintaining overall well-being during pregnancy as well as in preparing for labour, 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. Please ensure that you disclose all of your health information to your practitioner such that every effort will be taken to ensure the health and well being of both you and your baby.

Treatment is administered with the intention of helping to prevent miscarriage, alleviate morning sickness, relieve stress, treat insomnia, prevent gestational diabetes and/or hypertension, as well as to ease any aches & pains that may appear as your pregnancy develops. If there is not an active health issue that requires specific attention, during the third trimester at 34 weeks, the focus of treatments are on ensuring your baby is in the optimal position for labour. From 36 weeks onward, treatment is given to ready your body for labour and delivery. In all cases, treatment is selected and administered to assist your body in its natural process and timeline. We do not “induce” labour, this is a medical intervention that stimulates a natural process that has not yet occurred. At Yinstill, our focus is on relaxing the body, moving Qi and blood, and supporting you in allowing your body to begin this process.

Treatments administered are complementary to the care you are receiving from your primary care physician and are not meant as a replacement for this care. It is advised that you inform your primary care physician that you are receiving treatment at Yinstill during your pregnancy.

I understand that I will have an opportunity to discuss with the practitioner the nature of treatment to be received and any concerns I may have. I understand the results may not be guaranteed. I understand that I will be draped or remain clothed at all times and the areas undraped will be secure to insure there is no indecent exposure. If undraping my gluteal muscles is significant in the treatment I do understand that it is part of the therapy.

What are the possible side effects of acupuncture during pregnancy?
– Drowsiness can occur in a small number of patients, and if affected, you are advised not to drive;
– Minor bleeding or bruising at the site of the acupuncture needles;
– 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;
– Pneumothorax (collapse of a lung) is possible if practitioner actually penetrate the lung organ.
– Fetal distress
– Increase in contractions and potential instigation of labour
– Vaginal discharge or bleeding

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
– 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. Your practitioner is aware of these contraindications and will prescribe only what is suitable for you at your stage of pregnancy.

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 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 or are prone to rapid drops in blood pressure

1. You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not to be performed until you have had an opportunity to receive such information and to give your informed consent.

  • The procedure involves inserting a needle into your vein, and injecting the formula by your physician.
  • Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.
  • Rare risks of intravenous therapy include: i. Discomfort, bruising and pain at the site of injection. ii. Inflammation of the vein used for injection (phlebitis). iii. Severe allergic reaction, anaphylaxis, cardiac arrest, and death.
  • Benefits of intravenous therapy include: i. Injectables are not affected by gastrointestinal system or disease. ii. Total amount of infusion is available for the tissues and organs. iii. Nutrients enter cells by means of a high concentration gradient for maximum nutrient uptake. iv. Higher doses of nutrients can be given than possible by oral dosing without intestinal irritation.

2. You have the right to consent to or refuse any proposed treatment at any time prior to its performance. Your signature on this form affirms that you have given your consent to receiving intravenous infusions deemed safe and efficacious by your physician.
3. The procedures will be performed by or under the direction of the physician named above with qualified medical assistants (if required).
4. As bags for IV therapies are prepared on an as needed basis and for the individual patient, 24 hours notice MUST be given for a cancelled appointment. Without adequate notice, you will be charged for the treatment.

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.

Privacy Policy
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.

Appointment Policy
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 permission
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).

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