The Lotus Way and The AOM Scholarship Fund

Consent to Community Acupuncture Treatment 

Treatment Description 

Acupuncture is performed by placing thin, sterile, single-use needles on various point on the body. The needles are generally left in place for 35-45 min. Treatment time may need to be altered for clinical purposes by a State Licensed Acupuncturists. 

Voluntary 

I hereby voluntarily consent to be treated by acupuncture. I understand I may be treated with needles and/or small seeds/beads taped to my ears. 

I have not been guaranteed any success concerning the uses and effects of acupuncture treatment. I understand I am free to discontinue treatment at any time. 

Possible Side Effects/Healing Reactions 

I understand that acupuncture may result in certain side effects, including local bruising, sight bleeding, fainting, temporary pain and discomfort, and temporary aggravation of symptoms existing prior to treatment. Conventional medical therapy also may be indicated, either in response to an emergency or as deemed necessary at the discretion of a licensed physician. 

Medical Referral 

I understand if there is a worsening of my ailment or condition or if a new ailment or condition arises, that I should consult a licensed physician. I also understand that if I am currently under a physician’s care I should continue as long as my physician and I deem it necessary, and that my acupuncture providers do not recommend altering my medications or other therapies without first consulting my personal physician or provider. 

Infectious Disease/Clean Needle Procedures 

I understand that infectious diseases may be carried through the air, through physical contact, and through body fluids. I understand that acupuncture practitioners follow the prescribed national standards of Universal Precautions to guard against the spread of infection through the use of sterilized/ prepackaged disposable single-use needles. 

I further understand that I am responsible for cleaning my body (including face, ears, hands, and feet) prior to treatment.

Community acupuncture is a nationwide movement to create access to acupuncture by removing the barrier of cost from healing. Community clinics offer treatment in a group setting and charge on a sliding scale format ($20-50).  

We use points on the scalp, ears, and below the elbows and knees to treat the entire body, so there’s no need to undress – just remove your shoes and roll up your pants and sleeves. And yes, we can even address your back pain by treating your wrists.

You will be surrounded by other people quietly receiving treatment at the same time. Patients benefit many ways from the community setting. In our busy society, it is not often we stop and take time to relax while surrounded by our peers. This is not a lack of privacy but an opportunity to experience treatment with family, friends and community. As with any intentional group endeavor, the shared state makes individual treatments more powerful. Here, the patients create the healing atmosphere as much as the practitioner.