CONSENT FOR RECEIVING ACUPUNTURE: PHOTO RELEASE AND EVALUATION FORM

Please read carefully then sign your consent on the Group Consent Form

Regarding Acupunture

Ear acupuncture is a procedure where stainless steel needles are inserted at specific points on the ear. Ear seeds or ear magnets don’t puncture the skin. They are attached by adhesive and are easy to remove. All needles for acupuncture treatments are pre-packaged, sterile and disposable used in accordance with national Clean Needle Technique standards.

Both methods (with needles or seeds) have balancing effect on the body and help with stress. I understand this is not intended to replace medical attention. I, the undersigned, do affirm that I have been advised to consult a physician regarding the condition or conditions for which I seek acupuncture treatment. I have been informed that this is a generally safe method of treatment but may have side effects such as minor bruising or tingling near the insertion point, or occasional dizziness. I will notify the acupuncturist if I am or am trying to become pregnant, on blood thinners, have high/low blood pressure, or a history of fainting or seizures. My participation in this event is voluntary.

Regarding Photography and Other Recordings

Unless otherwise indicated, I, the undersigned, hereby authorize The Lotus Way and its staff and volunteers to take photographs , video images and sound recordings of me and my property at this event for inclusion in television, electronic media, print and other media, and to use and authorize others to use such images and recordings in all manner and media throughout the world and in perpetuity. I also agree that such pictures and recordings may be used by The Lotus Way, and their assignees for promoting and advertising their programs or productions.

Regarding Post-Treatment Evaluation Forms and Testimonials

You may be offered a post-treatment evaluation form. Completion of the evaluation form is completely voluntary and anonymous. By completing an evaluation form, you hereby consent to allow The Lotus Way to compile and use the data contained within the form in furtherance of The Lotus Way’s mission statement and organizational goals. If you provide a testimonial, you also hereby consent to and authorize the use of such testimonials by The Lotus Way in television, electronic media, print and other media, and to use and authorize others to use such testimonials in all manner and media throughout the world and in perpetuity. I also agree that such testimonials may be used by The Lotus Way, and their assignees for promoting and advertising their programs or productions.