Nuurvana Consent Form

Acupuncture Consent Form

Acupuncture is a healing therapy that involves inserting fine needles into specific points, along meridians on the body. It can reestablish and unblock the flow of Qi, or energy. In addition to the use of needles, the scope of acupuncture includes use of electrical, mechanical or magnetic devices to stimulate points, moxibustion, acupressure, cupping, gua sha, and/or essential oils.

All therapists, including the naturopathic/acupuncture modalities described above have the potential to create both desirable and undesirable effects. Of the latter, such effects can include the following: allergic reactions/sensitivities/adverse effects to recommendations of natural supplements and adjustments to making lifestyle modifications. Acupuncture side effects may include some pain following treatment in the insertion area, minor bruising, infection, needles sickness (fainting) and broken needle.

If you are pregnant, taking anti-coagulant drugs (Coumadin), have a severe bleeding disorder (hemophilia), heart-condition, diabetes, circulatory problems, blood clots, cancer/malignancies, bone disorders (osteoporosis, Paget’s disease, Multiple Myeloma), metal implants or have a pacemaker, you should make that information know to prior to treatment.

I have read and understood the information on this consent form.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by a Nuurvana Licensed Acupuncturist, regarding cure or improvement of my condition. I understand that I am free to withdraw this consent and discontinue participation of these procedures at any time.



Release Of Information

All information provided herein is true and correct. I hereby consent to treatment. I give permission to my provider and staff to release information, verbal and written, contained in my medical record and other related information to related health care providers, assignees and/or beneficiaries and other related persons. I have read and understood this release.



Physician Referral

While Oriental Medicine has a great deal to offer as a health care system, it cannot totally replace the resources available through biomedical physicians. Consequently, we recommend that you consult a physician regarding any conditions for which you are seeking acupuncture treatment.

We the undersigned do affirm that (patient), has been advised by a Nuurvana Licensed Acupuncturist to consult a physician regarding the condition or conditions for which such patient seeks acupuncture treatment.



Acknowledgement of Receipt of Notice of Privacy Practices

You may refuse to initial this acknowledgment:

I, , have received a copy of this office’s notice of Privacy Practices and I consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.



Payment Policy

Payment of all services rendered is due at the time of service. I have read and understood this policy.


Appointment Cancellation Policy

I understand that 48 hours notice is required when canceling an appointment. I also understand that the full cost of the visit will be charged should I cancel my Nuurvana session within less than 48 hours of my session time.



I understand that this one signature below indicates agreement to the above initialed terms of Nuurvana’s following forms: Acupuncture Consent Form, Release of Information, Physician Referral, Acknowledgement of Receipt of Notice of Privacy Practices, Payment Policy, and the Appointment Cancellation Policy.







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Signature Certificate
Document name: Nuurvana Consent Form
Unique Document ID: 3b9db278bf87664527cb611cd7930236a3ff4e9c
Timestamp Audit
2015-04-09 18:59:39 ESTNuurvana Consent Form Uploaded by Deganit Nuur - IP