To comply with Article 160, Section 8211.1 (b) of NYS Education Law, we request that you read the following statement and agree to it by providing an electronic signature of your name in the box below:

I/We, the undersigned, do affirm that I have been advised by (L.Ac.) Sharon Yeung to consult a physician regarding the condition(s) for which the above named patient seeks acupuncture and/or herbal medicine treatment.

I authorized the release of any medical or other information necessary to coordinate my treatment with my other licensed health-care providers.

Informed Consent to Treatment

I consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine by Sharon Yeung L.AC. and/or any other practitioner designated by Sharon Yeung, L.Ac. I have discussed the nature and purpose of my treatment with her.

I understand the methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Chinese massage (tuina), Chinese herbal medicine, and nutritional counseling.

I understand that needles will be inserted in my body and/or heat, pressure, or electrical stimulation will be applied to my body. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects including, but not limited to, bruising, numbness, or tingling near the needling site that may last a few days, and possible dizziness or fainting. Bruising is a side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although only disposable sterile needles are used, and clean techniques are practiced at all times in only safe environments. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I understand that acupuncture treatments are not always successful and that no guarantee or assurance has been given to me by anyone concerning the results of treatment.

The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that are recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. I understand that some herbs may be considered inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.

I understand that the herbs need to be prepared and the tea or pills consumed according to the instructions provided orally and/or in writing. The herbs may have an unpleasant smell or taste. I will immediately notify the practitioner of any unanticipated or unpleasant effects associated with the consumption of the herbal teas, pills, powders, or liniment use.

I will notify the practitioner who is caring for me if I become pregnant or are planning to get pregnant.

I have not been given a diagnosis of cancer by my physician or by a diagnosing physician. If I have been given such diagnosis or if I am given one while undergoing acupuncture treatment, I understand that the Acupuncture Service may not treat me unless I am under the care of a physician and receiving my cancer treatment under the supervision of such physician. I will inform the Acupuncture Service in my status relative to a diagnosis of cancer.

I do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment and I wish to rely on the practitioner to exercise judgment during the course of treatment which the practitioner thinks at the time, based upon the facts then known, is in my best interest.

By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions concerning above. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I understand that I have the option to discontinue treatment at any time.

24-HOUR Rescheduling notice

In order to honor my commitment to treatment and for treatment to serve me in the best possible manner, if I need to reschedule my appointment, I will give 24 hours, one full business day, notification. If I have not given this 24 hours notice prior to the scheduled appointment, I will kindly pay for the missed session by check in the mail or at the next treatment session.