Title: 2005 Consent Form
Author: Marguerite Dinkins

Marguerite Dinkins, L.Ac.   6363 7th Ave S Seattle, WA 98108. www.mdinkins.com

Consent For Traditional Chinese Medicine

I, the undersigned, hereby authorize Marguerite Dinkins, L.Ac. to perform the following specific procedures:

Chinese Herbs:	may be given in the form of pills, powders, tinctures, pastes, plasters, or in raw form to be cooked. Cooked herbs may be given to take internally or externally as a wash or soak. Herbal formulas may include shell, mineral, and animal products. Over 98% of the herbs used are botanical. If you do not want animal based products used in your formula, please notify Marguerite Dinkins, L.Ac. at every visit when herbs are prescribed.

Acupuncture: 	insertion of special sterilized needles through the skin into underlying tissues at specific points on the surface of the body. Because the needles are sterile and are only used one time, it is not necessary to swab the skin with alcohol prior to insertion; however, feel free to request this from your practitioner.

Tui Na: 	a form of therapeutic massage relying on specific hand techniques, pressure on acupuncture points, and isolated stretching. This technique involves close physical contact, during which practitioner may be on the treatment table with the patient.

Cupping: 	cups made of glass, bamboo, or other materials are placed on the skin with a vacuum created by heat or other device. Some bruising may result.

Plum Blossom or Seven Star Hammer:	light tapping of an area of the body with a small sterile hammer which has seven points.

Gua Sha:	rubbing on an area of the body with a blunt, round instrument. Some bruising may result.

Moxibustion: 	heating an acupoint using using stick, string, or ball moxa to create a warming effect.

I recognize the potential risks and benefits of these procedures as described below:
Potential risks:
discomfort, pain, infection or blistering at the site of the procedure; temporary discoloration of the skin; nausea; loose bowel movements; abdominal cramping; and aggravation of symptoms existing prior to the treatment. Treatment may also result in other unforeseen consequences.

Potential benefits:
drugless relief of presenting symptoms and improved balance of bodily energies, which can lead to prevention or elimination of the presenting problem, and strengthen the constitution. 

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Marguerite Dinkins, L.Ac. regarding cure or improvement of my condition.  I hereby release Marguerite Dinkins, L.Ac. from any and all liability which may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. I understand I am free to withdraw my consent and to discontinue participation in these procedures at any time.

Retroactive Effect:
If patient intends this agreement to cover services rendered before the date it is signed, patient should initial here. ________   Effective as the date of first professional services. 

__________________________________________________________		______________________
Signature of Patient or Guardian							Date
Consent TCM revised 2023–11-10