Acupuncture Consent Form
Company: Unity Health & Performance Ltd
Document Ref: ACU-FORM-001
Version: 1.0
Effective Date: 10/11/2025
Related Policy: Safe Practice of Acupuncture Policy (ACU-POL-001)
Part 1: Information for the Patient
1. The Treatment:
Acupuncture involves the insertion of sterile, single-use, fine needles into specific points on the body. It is used to promote natural healing, improve function, and reduce pain. The practitioner will discuss your specific condition and the proposed treatment plan, including the expected number of sessions and outcomes.
2. Potential Risks and Side Effects
While acupuncture is generally considered safe, you should be aware of the following potential risks:
Bruising & Bleeding. Minor bruising or small spots of blood may occur at the needle insertion site, particularly in those taking blood-thinning medications.
Fainting/Dizziness. Some patients may feel dizzy or lightheaded during or after treatment (vasovagal episode). Please inform the practitioner immediately if you feel unwell.
Pain/Discomfort. You may experience a dull ache, tingling, or electric sensation, known as 'De Qi', which is normal. Significant, sharp pain is not normal, and you must inform the practitioner if this occurs.
Infection. The risk of infection is extremely low due to the strict use of single-use, pre-sterilised needles and adherence to clinical hygiene protocols.
Pneumothorax. This is an extremely rare but serious complication involving the accidental puncture of the lung membrane. Needling sites near the chest are only treated by highly trained practitioners following strict depth and angle protocols.
Part 2: Patient Declaration and Consent
I, the undersigned patient, confirm that:
I have been informed about the nature and purpose of the proposed acupuncture treatment, as well as the alternative treatment options available.
I understand the potential risks and side effects associated with acupuncture, including the common occurrences (bruising, slight bleeding) and the rare, serious complications (pneumothorax, fainting).
I have had the opportunity to ask questions regarding the treatment, and these questions have been answered to my satisfaction.
I understand that I have the right to stop the treatment at any time and that my consent can be withdrawn at any point during my care.
I confirm that I have disclosed all relevant medical information, including current medication, allergies, pregnancy status, and any known blood clotting issues, to the treating practitioner.
I authorise the practitioner to administer acupuncture treatment as deemed clinically necessary and appropriate for my condition.
Part 3: Data Protection Statement
I understand that my personal data and sensitive clinical information will be collected, processed, and stored by Unity Health & Performance Ltd in accordance with the General Data Protection Regulation (GDPR) and the company's Privacy Policy. This information will be used solely for the purpose of providing safe and effective treatment and will be kept confidential.
