DBA: River Bend FM LLC-Kelly Neu L.Ac.
61555 Parrell Rd Bend, OR 97702
P: 541-318-1000 * F: 541-318-7050 * E: appointments@bendwellnessdoctor.com

Informed Consent: Acupuncture
The acupuncture meridian system encourages your body’s natural healing process. Acupuncture treatments commonly use disposable acupuncture needles, moxabustion, electric-stimulation, Kinesio-taping and massage techniques including cupping and gua sha to encourage self-healing. The side effects of these treatments include bruising or tingling near the needling sites that may last a few days. There may be some bruising after cupping or gua sha, which is considered a normal response. The risks of acupuncture are very rare and include fainting, infections, and scarring. In extremely rare instances pneumothorax has been reported. 
• I understand and consent to any combination of the above treatment approaches during my appointments. 
• I have been given the opportunity to ask questions about recommended treatment options and their associated risks. 
Herbs, topical oils and creams, and nutritional supplements (from plant, animal, and mineral sources) are commonly recommended and are considered safe in the practice of Chinese medicine. These supplements also affect the meridian system and provide nutrients your body needs to self-heal. If you are a woman and become pregnant while under our care you will need to notify us immediately to review your current treatment approach and supplements. 
• I understand and agree to notify my acupuncturist if I experience any gastrointestinal symptoms or allergic reactions from recommended herbs, essential oils, or supplements. 
• If I become pregnant I will immediately notify my acupuncturist to review current herb, topical, and supplement recommendations. 
All of your medical records are kept confidential and will not be released without your written consent. We recommend contacting your insurance company to verify if reimbursement is available. If you are filing for insurance reimbursement then your insurance company has rights to your medical records and billing information. • I understand that I am responsible for my bill. 
• I authorize the release of information to all of my insurance companies. 
• I permit a copy of this authorization to be used in place of the original. 
• I intend this consent form to remain in force during my care. 
• I understand a $25 cancellation fee may be charged if I cancel with less than 24 hours notice.
• I authorize the use of my treatment results for educational purposes with my identity remaining anonymous and confidential. 
Consent
• I have read and understand all of the above, and authorize care to be administered as deemed necessary. 

Printed name of patient :_______________________________________________________________ 
Signature of patient :__________________________________________________ Date:_______________________________ 

(If Applicable) Consent To Treat A Minor 
Printed name of parent or guardian _____________________________________________
Relationship to minor ________________________________________