Bluemoon Acupuncture and Wellness Center

Mojgan Rezaei, L.Ac., MAOM

Informed Consent and Privacy Policy

I hereby request and consent to the performance of Oriental Medicine treatments, including acupuncture and other procedures, on me by Bluemoon Acupuncture and Wellness Center and any other licensed acupuncturists/practitioners of Oriental Medicine who now or in the future may treat me while employed by, working with, or associated with Bluemoon Acupuncture.

I understand that Oriental Medicine treatments may include, but are not limited to:

• Acupuncture

• Electro-acupuncture

• Moxibustion

• Cupping

• Tuina

• Gua Sha

• Traditional Chinese herbal medicine

• Qigong

• Lifestyle and dietary counseling

I understand that herbs may need to be prepared and consumed as instructed, either orally or in writing. Herbal teas may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff if I experience any unanticipated or unpleasant effects from the consumption of herbs.

I understand that acupuncture is generally a very safe method of treatment with few, but possible, side effects, including:

• Bruising

• Numbness at the needle site

• Dizziness or fainting

I acknowledge that bruising is a common side effect of cupping and Gua Sha. Moxibustion and heat therapies may, in rare cases, cause burns or scarring. Chinese herbs (from plant, animal, and mineral sources) are considered safe when prescribed by professional practitioners of Oriental Medicine, although some may be toxic in large doses. I understand that many herbs are inappropriate during pregnancy and may also interact with other herbs or prescription medications.

I will notify staff if I become, or suspect that I am, pregnant. I will also inform staff of any drugs (medicinal or recreational) and supplements I am taking, as well as any changes to them. I do not expect the clinical staff to be able to anticipate or explain all possible risks or complications, and I understand that results cannot be guaranteed.

I understand that clinical and administrative staff may review my patient records, but all records will remain confidential and will not be released without my written consent.

I also understand that Bluemoon Acupuncture and Wellness Center may, from time to time, send me information by mail or email, including receipts, newsletters, and office announcements. My name and contact information will never be released to any other business or organization.

I have been notified that the full privacy policy of Bluemoon Acupuncture and Wellness Center is available online, and I may request a printed copy if I wish.

By voluntarily signing below, I acknowledge that I have read (or had read to me) this consent to treatment, have been informed of the benefits and risks of the above procedures, and have had the opportunity to ask questions.

I intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment.