WPC  N%ܩA}o'>6e{xc鑊ޣ}*#y+CYa_aQ\7J KG:ef6G@m#Bp^Fؖ;-.l?{XYwqyI|eY>L I*Yv4:7kY!OEk@/<,$䃎!w:V3W~p di>ڝ745tx?ΰc88 j:{~T xAa(%꦳R? ?[.+Ym@yo|ox-yFPv]@?ǰg}O{$@UwkI%ē %Op!LѡUUgYsDD-ZyҧIq*Fzܲ T^hO?cd*A"ױ9zw;G{['gh5BO8h%#UN % 0:#UH]U.U*^ w 4 !0 m2U@IIIIIIIIIIIII 0( 01 D+] Kyocera CS-3050 (KPDL)0(9 Z6Times New Roman RegularX($USUS., $0AGaramondPro-Regular $TektoMM\  `Times} ; L"9pdocs3|xU(9 Z(Times New Roman <tx:NormalParagr33XXX?\  `Times?#ddC $TektoMMC#dd,*body;14 <DL!;33XXX] $0AGaramondPro-Regular]#ddC $TektoMMC#dd;14 <DL!;'dxd !USUS.,   XIXXXaXXI  AcupunctureInformedConsent #XIXa##XtXXXIh#XىXXXt  #XtXXXى#XtXXXt0XXt33XtX0XtXXXtX1 XXXtXىX XX1#dddd  XtXXXى  ݌̌0XXt00000033#dddd  E14 <DL!XE K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(XYK     #XtXXXt#0XXtIherebyrequestandconsenttotheperformanceofacupuncturetreatmentsandotherprocedureswithinthescopeofthepracticeof Y acupunctureonme(oronthepatientnamedbelow,forwhomIamlegallyresponsible)bytheacupuncturistnamedbelowand/or 0` otherlicensedacupuncturistswhonoworinthefuturetreatmewhileemployedby,workingorassociatedwith,orservingasbackup 7 fortheacupuncturistnamedbelow,includingthoseworkingatthisofficeoranyotherofficeorclinic,whethersignatoriestothis  formornot. _݌  Ќ00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(X K )    ) ݌̌00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(Xc K    Iunderstandthemethodsoftreatmentmayinclude,butarenotlimitedto,acupuncture,acupre  ssure,moxibustion,cupping,electrical c  stimulation,TuiNa(Chinesemassage),Chineseherbalmedicine,andnutritionalcounseling.  y ݌ : j  Ќ00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(X A K    F݌̌00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(X  K T  Ihavebeeninformedthatacupunctureisasafemethodoftreatment,butthatitmayhavesideeffects,includingbruising,numbness    ortinglingneartheneedlingsitesthatmaylastafewdays,anddizzinessorfainting.IunderstandthatIshouldnotmovewhilethe   needlesarebeinginserted,retained,orremoved.Bruisingisacommonsideeffectofcupping.Unusualrisksofacupunctureinclude   spontaneousmiscarriage,nervedamageandorganpuncture,includinglungpuncture(pneumothorax).Infectionisanotherpossible m  risk,althoughtheacupuncturistbelowusessteriledisposableneedlesandmaintainsacleanandsafeenvironment.Burnsand/or Dt  scarringareapotentialriskofmoxibustion.Iunderstandthatwhilethisdocumentdescribesthemajorrisksoftreatmentotherside K effectsandrisksmayoccur. T݌ " Ќ00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(XK    b݌̌00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(XK p  Theherbsandnutritionalsupplements(whicharefromplant,mineral,andanimalsources)thathavebeenrecommendedare  traditionallyconsideredsafeinthepracticeofChineseMedicine,althoughsomemaybetoxicinlargedoses.Iunderstandthatsome w herbsmaybeinappropriateduringpregnancy.Somepossiblesideeffectsoftakingherbsarenausea,gas,stomachache,vomiting, N~ headache,diarrhea,rashes,hives,andtinglingofthetongue.Iwillimmediatelynotifytheacupuncturistofanyunanticipatedor %U unpleasanteffectsassociated#bbddwiththeconsumptionoftheherbs.IwillnotifytheacupuncturistwhoiscaringformeifIamorbecome , pregnant#ddbb. p݌  Ќ00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(XK M!   M!"݌̌00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(XK #  Idonotexpecttheacupuncturisttoanticipateandexplainallrisksandcomplicationsoftreatment,andIwishtorelyonthe  acupuncturisttoexercisejudgmentduringthecourseoftreatmentwhichtheacupuncturistthinksatthetime,baseduponthefacts X thenknown,isinmybestinterest.Iunderstandthatresultsarenotguaranteed.Iunderstandtheofficemedicalandadministrative /_ staffmayreviewmymedical#eeddrecordsandlabreports,butallmyrecordswillbekeptconfidentialandwillnotbereleasedwithout 6 mywrittenconsent.#ddee #%݌   Ќ00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(XK Q)   Q)*݌̌00000000#dddd*XX*   K14 <DL!XK33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX0XXt33K$(X K ,  ByvoluntarilysigningbelowIshowthatIhaveread,orhavehadreadtome,thisconsenttotreatment,havebeentoldabouttherisks   andbenefitsofacupunctureandotherprocedures,andhavehadanopportunitytoaskquestions.Iintendthisconsentformtocover b! theentirecourseoftreatmentformypresentconditionandforanyfuturecondition(s)forwhichIseektreatment.#XtX0#&e%XXt ,-݌ 9 i" Ќ0%&e000000#dddd*XX*    ' j#X' H14 <DL!H33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(X!@ K 0  #XtXXXt/#?|=XXt 0^2݌̌0=?|000000#dddd' X'   H14 <DL!H33XtX0XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(X"8 K 3  #XtXXXt2#?|=XXtPatientsName 3<5݌ "8$ Ќ0=?|000000#dddd' X'  K$(X[# K#XtX0~5#?|=XXt'j#'PatientsSignature0  DateSigned[# &%%  K14 <DL!j#K33XtX=?|XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(X$! K 7  #XtXXXt7#?|=XXt 719݌̌?|==?|?|==?|#dddd*j#X*  Tobecompletedbythepatientsrepresentativeifthepatientisaminororisphysicallyorlegally &1#* incapacitated: T'$, K$(X(%KPrintNameofPatient (%.  K14 <DL!j#K33XtX=?|XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(X)*'K Z;  #XtXXXts9#?|=XXtPrintNameofPatientRepresentative Z;<݌ )*'0 Ќ?|==?|?|==?|?|==?|?|==?|#dddd*j#X*  K$(XM+}(KSignatureofPatientRepresentative M+}(2  K14 <DL!j#K33XtX=?|XtXXXtX1 XXXtX X XX1#dddd  XtX XX33K$(X,)K >  #XtXXXt=#?|=XXtRelationshiporAuthorityofPatient >i@݌ ,)4 Ќ?|==?|?|==?|?|==?|?|==?|#dddd*j#X*  #XtX=?|@#?|=XXtNameofAcupuncturist#XtX=?|B##XtXXXtn#