Informed Consent for Cosmetic Acupuncture

    This document is meant to inform you about Cosmetic Acupuncture, the risks involved and possible alternatives. It is important that you read this information carefully and completely and then sign the consent.
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    Please be advised facial acupuncture is not a surgical procedure and is no way analogous to, or a substitute for, a surgical face-lift.
     
    The goal of Cosmetic Acupuncture is to enhance appearance, improve health, and create a sense of inner and outer well-being. Cosmetic Acupuncture is an organic, gradual process that is customized for each individual.

    BENEFITS:
    • Eliminate fine lines and soften deeper wrinkles
    • Improve skin texture, color, luster, and appearance
    • Increase energy in skin cells and skin tissue
    • Tone, relax, nourish, and balance facial and neck muscles
    • Decrease puffiness around the eyes
    • Bring more firmness to sagging skin
    • Enhance radiant complexion
    • Enhance overall appearance
    • Improve health
    • Regulate Organ and Meridian disharmony
    • Reduce physical, mental, and emotional imbalances

    ALTERNATIVES: Other options to improve aging appearance are surgical facelift, Botox injections, fillers, chemical face peels, laser therapies, or liposuction. Risk and potential complications are associated with these alternative forms of treatment.

    THE MAJORITY OF PATIENTS DO NOT EXPERIENCE THESE RISKS OF COSMETIC ACUPUNCTURE.

    • ASYMMETRY: The human face is normally asymmetrical. Thus, there can be a variation from one side to the other in the results attained from a facial acupuncture treatment.
    • BLEEDING: It is possible, though very unusual, that you have a few drops of bleeding at a needle site.
    • BRUISING: There is a possibility of bruising, puffiness, blood, tingling, itching, warmth, pain or other symptoms at the site of the needle.
    • HEALTH INSURANCE: Most health insurance companies exclude coverage for acupuncture facials.
    • INFECTION: Infection is very unusual, antibiotics may be necessary.
    • INJURY: Blood vessel, muscle or nerve damage rarely results from facial acupuncture, the injury may be temporary or permanent. Injury to nerves rarely results from facial acupuncture treatments. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to sensory nerves of the face, neck and ear regions may cause temporary or, more rarely, permanent numbness. Painful nerve scarring is very rare.

    LONG-TERM EFFECTS: Acupuncture facials do not stop the aging process or produce permanent tightening of the face and neck. Future Cosmetic Acupuncture treatments may be necessary to maintain the results. You may be disappointed with the results from Cosmetic Acupuncture.

    DISCLAIMER: Informed-consent documents communicate information about a proposed procedure along with disclosure of risks and alternative forms of treatments. Informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Your acupuncturist may provide you with different information that is based upon your particular case and current knowledge within the field of acupuncture. Informed consent documents are not intended to define the standard of acupuncture. Standards are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

    It is important that you read the above information carefully and have all of your questions answered before signing the consent below.
    Consent for Cosmetic Acupuncture Treatment
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    By filling my name and dating this online consent form, I hereby consent to treatment and authorize Ronit Gesundheit to perform Cosmetic Acupuncture. I acknowledge that no guarantee has been given as to the results that may be obtained. I understand the risks and alternatives. I am satisfied with all the explanations. 
    Ronit Gesundheit, L.Ac.