Vital Qi Event Waiver

Informed Consent to Treat

I hereby request and consent to the performance of acupuncture treatments and other modalities within the scope of practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Vital Qi, LLC practitioners including Elizabeth Fuqua, L.Ac., Nancy Talley, L.Ac., Ali Warters, L.Ac., or other licensed acupuncturists who now or in the future treat me while serving as her substitute. I understand that methods of treatment may include acupuncture with sterile and disposable needles, Tui-Na massage, cupping, Chinese herbal medicine and nutritional counseling. I understand that acupuncture is a safe method of treatment, but side effects may include bruising or tingling near the needling sites, dizziness or fainting. Extremely rare risks include nerve damage, organ puncture and spontaneous miscarriage. I agree to inform the acupuncturist if I am or become pregnant. 

I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment. If there is reasonable cause to believe that treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol, or appears to be overly medicated, then a treatment may not be performed at that time. In this case the patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment.

I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when the patient has not eaten properly before the time of treatment, and may result in dizziness, sweating, light headed feeling or other experiences similar to low blood sugar symptoms.

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

I understand the clinical and administrative staff 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.

I have read, or have had read to me, the above “treatment information” and “informed consent.” I have also had an opportunity to ask questions about the content, and by signing below I agree to the above-named procedures. I intend this consent from to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.