Page 2 – Informed Consent (Sign here) ---

Informed Consent for TCM Services

Practitioner: _______________________ L.Ac.

License#: ________________________ | Phone: __________________________

1.     Services Description (Practitioner will check applicable items)

[ ] Tuina for Pain & Whole-Body Balance (non-chiropractic)

Manual therapy based on TCM meridian theory to relieve pain, improve
mobility, and support overall balance, No spinal manipulation.

[ ] Stationary Cupping (negative pressure cups, home use)

Each session < 10 minutes. See Page 4 for risks.

[ ] Classical Herbal Medicine (Jing Fang)

Custom herbal formulas based on classical TCM pattern diagnosis,
Requires separate signed Voluntary Use Statement (Page 5).

[ ] Acupuncture (expected late 2026)

Sterile disposable needles. May cause minor bleeding, bruising, or dizziness.

2.General Risks & Benefits

• These TCM therapies aim to regulate the body and relieve symptoms.
No specific outcome is guaranteed.

3.Patient’s Responsibility & Emergency Disclaimer

• I will immediately inform the practitioner of any discomfort during treatment.

• TCM does NOT replace emergency care. If symptoms worsen or a
critical condition occurs, I will go to a hospital immediately.

4. Patient Acknowledgement

I have read and understood the above, had the opportunity to ask
questions, and received satisfactory answers. I voluntarily consent to
the TCM services provided by the practitioner.

Patient signature: ____________________ | Date: ______________________

Practitioner signature: ________________________