I understand that my treatment may include one or more of the following modalities, based on my provider’s clinical judgment:

• Acupuncture: The insertion of sterile, single-use needles into specific points to support the body’s natural healing processes. Risks may include minor bleeding, bruising, soreness, or, in rare cases, dizziness or fainting.

• Craniosacral Therapy: A gentle, hands-on approach to release tension in the craniosacral system using light touch to the head, spine, sacrum, or related areas. Temporary physical or emotional responses may occur.

• Cupping Therapy: A suction technique using cups to improve circulation and release tissue tension. Cupping may leave circular marks or discoloration that can last several days.

• Gua Sha: A scraping technique using a smooth tool to release stagnation and support circulation. This may cause temporary red or purple marks that typically fade within a few days.

• Moxibustion (Moxa): The use of warming herbal heat (mugwort) near or on the body to stimulate healing. Care will be taken to avoid burns or discomfort.

• Electroacupuncture: A mild electrical current applied to acupuncture needles to enhance therapeutic effect. Sensations may include tingling or pulsing.

• Tui Na & Manual Therapies: These may include pressure, mobilization, and massage techniques rooted in East Asian medical traditions. Mild soreness may occur.

• Chinese Herbal Medicine: I may be prescribed customized herbal formulas in pill, tincture, or tea form. I agree to follow dosage instructions and notify my provider of any side effects, allergies, or medication interactions.

I understand that these therapies are generally safe but not a substitute for emergency medical care or primary care diagnosis.

I agree to inform my provider of:

• Any current or suspected pregnancy, as certain techniques and herbs may be contraindicated during pregnancy.

• Any medical conditions such as bleeding disorders, seizure disorders, heart conditions, implanted medical devices (like pacemakers), or known allergies.

• Any changes in my health, medications, or relevant diagnoses.

I understand that I may stop treatment at any time and that all personal health information will be kept confidential within the limits of the law.

By signing below, I give my voluntary and informed consent to receive care using the modalities listed above.