ACUPUNCTURE TREATMENT CONSENT, ASSUMPTION OF RISK & LIABILITY WAIVER

CONSENT TO ACUPUNCTURE TREATMENT

By completing and submitting this form, I voluntarily consent to receive acupuncture treatment provided through the Maryland Association of Acupuncture & East Asian Medicine (MAAEAM) by a licensed acupuncture practitioner or authorized provider acting within the scope of their licensure.

I understand that acupuncture involves the insertion of sterile, single-use needles into specific points on the body for therapeutic purposes.

ACKNOWLEDGMENT OF RISKS

I understand and acknowledge that acupuncture, while generally safe when performed by a qualified practitioner, involves inherent risks, including but not limited to:

  • Minor bleeding, bruising, or soreness

  • Temporary pain, fatigue, or dizziness

  • Fainting or lightheadedness

  • Temporary aggravation of symptoms

  • Skin irritation

  • Rare risks such as infection, nerve irritation, or injury

I acknowledge that no guarantees or assurances have been made regarding the outcome of treatment.

MEDICAL DISCLOSURE & RESPONSIBILITY

I affirm that I have fully disclosed all relevant medical information, including but not limited to:

  • Pregnancy or possibility of pregnancy

  • Bleeding disorders or use of anticoagulant medications

  • Pacemakers or implanted medical devices

  • Chronic illnesses or recent surgeries

I understand that failure to disclose relevant health information may increase the risk of adverse effects.

I agree to immediately notify the practitioner of any discomfort, pain, or adverse reaction during or after treatment.

NO MEDICAL DIAGNOSIS OR EMERGENCY CARE

I understand that acupuncture is a complementary healthcare service and is not a substitute for medical diagnosis, treatment, or emergency medical care. I agree to seek appropriate medical attention for any medical emergency or serious condition.

ASSUMPTION OF RISK & RELEASE OF LIABILITY

I knowingly and voluntarily assume all risks associated with acupuncture treatment.

To the fullest extent permitted by law, I hereby release, waive, discharge, and hold harmless the Maryland Association of Acupuncture & East Asian Medicine (MAAEAM), its officers, directors, employees, contractors, volunteers, and affiliated practitioners from any and all claims, demands, actions, or causes of action arising out of or related to my participation in acupuncture treatment, except in cases of gross negligence or willful misconduct.

ELECTRONIC SIGNATURE & LEGAL ACKNOWLEDGMENT

By completing and submitting this form, I acknowledge and agree that:

  • I have read and fully understand this document

  • I have had the opportunity to ask questions

  • I am voluntarily consenting to treatment

  • I understand that submission of this form constitutes my legal electronic signature

  • My electronic signature is legally binding and has the same force and effect as a handwritten signature