2140 Artesia Blvd. Unit A.
Torrance, CA† 90504
CONSENT FOR EXAMINATION AND TREATMENT
I understand that the risks of acupuncture and oriental medicine treatments include but are not limited to: minor bleeding, local bruising, fainting, temporary pain or discomfort and the possible temporary aggravation of prior existing symptoms.† In taking herbal supplements, the risk includes but is not limited to allergic reactions to supplements.†
I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on her to exercise judgment during the course of the procedure, based on the facts then known, which are in my best interests.
I have read and have had read to me, the above consent.† By signing below, I agree to the above named procedures.† 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.
Patientís name (print)____________________________________________________
Patient or Guardian Signature: ________________________________Date:_________
I have verbally explained the risks, benefits and alternatives to care.† The patient agrees to treatment.
Nadine Shozuya, L.Ac.††††††††††††††††††††††††††††††††††††††††††† Date