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Zen Interior Design

Informed Consent


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You are authorizing a licensed acupuncture physician (”Physician”) to perform reasonable and necessary medical examination, testing, and treatment (“Services”) to address your health complaints/concerns. Services may include, but are not limited to, the following:

a) Physical hands-on examination (tissue palpation);

b) Acupuncture and acupuncture-related therapies, including, but not limited to, dry needling, electrostimulation, infrared therapy, laser therapy, manual therapy, cupping, and point bleeding;

c) Percutaneous substance administration, including, but not limited to, intramuscular injections, subcutaneous injections, intradermal injections, trigger point injections, acupuncture point injections, and medication electrophoresis.

Picture of informed consent in English

Healing is an inherently unpredictable and inexact process. Physician makes no express or implied predictions, representations or promises whatsoever regarding Services, their duration, and results. Services may fail to cure your condition or, in some rare instances, may even make it worse. Should your condition fail to improve, it is your responsibility to inform your primary care provider. You may decline any treatment or test at any time before or during the visit. You are free to terminate care at any time for any reason or without one.


The potential side effects of Services while rare may include, but are not limited to, the following:


  • MOST COMMON: Skin marks, bruising, irritation

  • Local tenderness, numbness, tingling, hypersensitivity lasting several days

  • Dizziness, fainting, nausea, tachycardia, low blood pressure, headache

  • Puncture of organs and nerves

  • Miscarriage

  • Death


Physician can neither anticipate nor explain all possible risks, complications, and side effects associated with Services. Should you experience any unanticipated or serious adverse effects while/after receiving Services, you must notify Physician. In case of emergency, contact your local emergency medical services (911) immediately!


Physician is not responsible for the loss of, damage to, or theft of your vehicle and personal possessions while receiving Services.

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