Informed Consent & My Role in Care
I understand that I am the decision-maker for my health care. Part of this clinic's role is to provide me with the information I need to make informed choices about the recommended care, its benefits and risks, the alternatives, and the potential effect on my health if I choose not to receive care.
I understand that acupuncture is not intended to substitute for diagnosis or treatment by a physician and is not an alternative to necessary medical care. Assessments and statements made by the practitioner are based on acupuncture and Oriental medicine and are not a Western medical diagnosis. It is expected that I am under the care of a primary care physician, M.D., D.O., or specialist as appropriate, that pregnant patients are managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.
Consent to Treatment
I request and consent to the performance of acupuncture treatments and other procedures within the scope of acupuncture practice on me (or on the patient named below, for whom I am legally responsible) by Tony Willcox, AP, and by other licensed acupuncturists who now or in the future treat me while employed by, working with, associated with, or serving as back-up for this clinic.
Scope of Practice & Modalities
The modalities used at this clinic include, but are not limited to:
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Use of acupuncture needles to stimulate acupuncture points.
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Dry needling — insertion of filiform needles into myofascial trigger points to help release muscle tension and support pain relief.
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Laser therapy — K-Laser (Class IV) or THOR Laser (Class 3B), used to support endorphin release, help manage pain, and support the body's healing.
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Infrared heat therapy — applied to the skin to help increase local circulation, ease muscle tension, and support the body's healing.
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Micro-current or electroacupuncture may be applied to acupuncture needles.
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Fire cupping — suction cups applied to areas of the body to help ease tight muscles and support circulation.
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Gua Sha or Dermal Friction Technique — applied to the skin to support the circulation of soft tissue.
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NovoTHOR red light (photobiomodulation) therapy.
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Chinese herbal medicine / nutrition.
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Vitamin/nutrient injections — administered via injection to help support energy, wellness, and recovery.
If herbs are recommended, I will follow the instructions provided to me orally and in writing, and I will promptly notify the clinic of any unexpected or unpleasant effects.
Possible Risks & Side Effects
Acupuncture is generally a safe method of treatment, but as with all healthcare, there are risks as well as benefits. While serious reactions are uncommon, I understand that the following may occur:
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Bruising, minor bleeding, soreness, or numbness or tingling near the treatment sites that may last a few days.
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Dizziness or fainting during or after treatment.
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Burns or scarring from fire cupping, laser therapy, or heat lamps.
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Skin redness, marking, or discoloration from cupping or Gua Sha (bruising is a common effect of cupping).
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Infrared/heat therapy may cause temporary skin redness, warmth, or in rare cases, mild burns or irritation, particularly with prolonged exposure or in areas of reduced sensation.
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Infection. To minimize this risk, the clinic uses sterile, single-use disposable needles and maintains a clean environment.
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Uncommonly, most often with needling near the chest, upper back, or neck, nerve damage or organ puncture, including pneumothorax (collapsed lung).
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From herbs and supplements (plant, animal, and mineral sources), traditionally considered safe but potentially toxic in large doses: possible nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, or tingling of the tongue, and, rarely, effects on the liver or kidneys.
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Other side effects and risks not listed here may also occur.
Pregnancy & Nursing
Some acupuncture points and some herbs are not appropriate during pregnancy. I will notify the clinic if I am, or become, pregnant or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted my obstetrician. Pregnant patients should be co-managed by an appropriate healthcare professional.
Voluntary Care, Clinical Judgment & Results
My participation in care is voluntary, and I may decline or discontinue any treatment at any time. I rely on the clinical staff to exercise their judgment during the course of treatment based on the facts then known and in my best interest. I understand that, as with all healthcare, results are not guaranteed and that no promise or guarantee of cure has been made.
My Responsibilities & Confidentiality of Records
I understand that I must fully inform the clinic of my medical history, relevant family history, and all medications and supplements I take (prescription and over-the-counter), and keep this information current. Clinical and administrative staff may review my patient records and lab reports; my records will be kept confidential and will not be released without my written consent, except as permitted or required by law.
Treatment Alternatives & Right to a Second Opinion
I understand there are options for my condition other than acupuncture procedures, which may include, but are not limited to, self-administered care, over-the-counter pain relievers, rest and physical measures, medical care with prescription medication, physical therapy, bracing, injections, and surgery. I understand that I have the right to a second opinion and to seek other options about my circumstances and healthcare as I see fit.
Informed Consent & Assumption of Risk
Knowing that some risk always accompanies treatment, and having been informed of the risks, benefits, and alternatives described above, I voluntarily consent to receive these treatments from Tony Willcox, AP, and the staff of Acupuncture Zen, and I accept the ordinary risks associated with this care.
Package & Scheduling Policy
All treatment packages are sold to and reserved for a single, named patient and are non-transferable. Package rates are discounted for that patient's individual plan of care; sessions may not be shared with, split among, gifted to, or transferred to any other person, including spouses or family members.
Package sessions are valid for two (2) years from the date of purchase and hold no cash value after they expire. All goods and services, including treatments, packages, herbal products, creams, oils, and patches, are non-refundable.
I agree to provide at least 24 hours' notice to reschedule or cancel an appointment. A prepaid package session that is missed without notice, or canceled with less than 24 hours' notice, may be deducted from the package as a completed session.
Gift Cards
Gift cards are available and are governed separately from the package terms above. Gift card value is handled in accordance with applicable Florida law.
Patients Under 18 (Minors)
If the patient is under 18 years of age, a parent or legal guardian must read this form, provide consent, and sign below on the patient's behalf, and represent that they have the authority to consent to care for the minor.
Electronic Signatures
Both parties agree that this agreement may be signed electronically, and that the electronic signatures on this agreement have the same effect as handwritten signatures for purposes of validity, enforceability, and admissibility.
Acknowledgment & Signature
By voluntarily signing below, I confirm that I have read, or have had read to me, this consent to treatment; that I have been informed of the risks and benefits of acupuncture and the other procedures described; and that I have had the opportunity to ask questions. I agree with the current and future recommendations for my care. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment at this clinic.
