Informed Consent

Consent to Treatment

Verdae LLC doing business as Verdae Wellness

Informed Consent for Acupuncture, Traditional Chinese Medicine, and Herbal Medicine

I understand that I am the decision-maker for my healthcare. Part of the role of Verdae LLC doing business as Verdae Wellness is to provide information that helps me make informed decisions regarding my care.

This process is commonly referred to as informed consent, which includes my understanding and agreement regarding:

• The care being recommended
• The potential benefits and risks of that care
• Available alternatives
• The potential effect on my health if I choose not to receive the recommended care

I understand that acupuncture and Traditional Chinese Medicine are not intended to replace diagnosis or treatment by a licensed medical physician or other qualified healthcare provider. It is expected that patients maintain appropriate relationships with their primary care provider or medical specialist.

Pregnant patients should be under the care of a qualified healthcare provider for pregnancy management, and patients seeking adjunctive cancer care should remain under the supervision of an oncologist or appropriate specialist.

Authorization for Treatment

I hereby request and consent to acupuncture treatments and other procedures within the scope of the practice of acupuncture and Traditional Chinese Medicine to be performed by practitioners associated with Verdae LLC doing business as Verdae Wellness.

This may include the treating acupuncturist and other licensed practitioners who may now or in the future treat me while employed by, associated with, or providing coverage for Verdae LLC doing business as Verdae Wellness.

Methods of Treatment

I understand that treatment methods used in Traditional Chinese Medicine may include, but are not limited to:

• Acupuncture (insertion of sterile, single-use needles)
• Moxibustion (heat therapy using herbal preparations)
• Cupping therapy
• Electrical stimulation of acupuncture needles
• Tui Na (Chinese therapeutic massage)
• Gua Sha
• Chinese herbal medicine
• Nutritional counseling
• Lifestyle and wellness recommendations based on Traditional Chinese Medicine principles

If herbal medicine is recommended, I understand that:

• Herbal formulas may require preparation according to verbal or written instructions.
• Herbal medicines may have a strong smell or taste.
• I will follow preparation and dosing instructions carefully.
• I will notify the practitioner immediately if I experience any unexpected or unpleasant effects.

Risks of Treatment

I understand that acupuncture is generally considered a safe method of treatment when performed by a licensed practitioner using sterile, single-use needles.

However, as with all healthcare procedures, certain risks may occur, including but not limited to:

• Bruising
• Mild bleeding
• Temporary numbness or tingling near needle insertion sites
• Dizziness or fainting
• Temporary soreness or discomfort

Certain treatments may also carry additional risks:

Moxibustion, heat therapy, or heat lamps

• Possible burns or skin irritation

Cupping therapy

• Bruising or temporary skin discoloration

Rare but possible risks of acupuncture include:

• Nerve irritation or damage
• Organ puncture (including lung puncture/pneumothorax)
• Infection

I understand that Verdae LLC doing business as Verdae Wellness uses sterile, disposable needles and maintains strict sanitation and safety protocols to minimize these risks.

Risks of Herbal Medicine

Herbal medicines and nutritional supplements recommended within Traditional Chinese Medicine are derived from plant, mineral, or animal sources and are traditionally considered safe when used appropriately.

However, potential side effects may include:

• Nausea
• Gas or stomach discomfort
• Vomiting
• Diarrhea
• Rash or hives
• Headache
• Tingling sensations
• Possible liver or kidney irritation

I understand that herbs may not be appropriate during pregnancy or while nursing.

I agree to immediately notify my practitioner if:

• I am pregnant or become pregnant
• I am nursing
• I experience any unusual reactions

If pregnancy occurs, I understand that I should discontinue herbal supplements until I have consulted with my practitioner and/or obstetrician.

No Guarantee of Results

I understand that healthcare outcomes vary between individuals.

While acupuncture and Traditional Chinese Medicine may support health and wellness, no guarantees or promises of cure or specific results have been made.

Responsibility to Provide Accurate Health Information

I understand that it is my responsibility to provide accurate and complete health information to my practitioner, including:

• Medical history
• Family medical history
• Current medical conditions
• Prescription medications
• Over-the-counter medications
• Vitamins or supplements

I agree to update this information if changes occur.

I understand that clinical and administrative staff may review my records and relevant medical reports as part of my care.

All patient records will be kept confidential in accordance with HIPAA and applicable privacy laws, and will not be released without my written consent unless required by law.

Alternative Treatment Options

I understand that there are treatment options available other than acupuncture and Traditional Chinese Medicine.

These may include:

• Self-care and lifestyle changes
• Over-the-counter medications
• Physical therapy
• Prescription medications
• Medical procedures or injections
• Surgical interventions

I understand that I have the right to seek a second opinion or alternative care at any time.

Consent

By signing below, I confirm that:

• I have read or had read to me this Consent to Treatment form.
• I understand the information provided.
• I have had the opportunity to ask questions.
• My questions have been answered to my satisfaction.
• I voluntarily consent to treatment provided by Verdae LLC doing business as Verdae Wellness.

This consent applies to the treatment of my current condition as well as any future conditions for which I seek care.