​​​                  IRIE Natural Center For Health
                              Dr. Sonya M. Johnson

       Consent for Acupuncture, Cupping and Moxibustion Therapies 

Acupuncture, cupping and moxibustion are all therapies of Oriental Medicine. Acupuncture includes the insertion of sterile disposable needles at points in the body indicated by the methods of diagnosis specific to Oriental Medicine. Heat lamps and/or mild electric stimulation may be applied to the needles during the acupuncture treatment. 

Moxibustion a procedure using a burning herb to warm specific points may also be applied. 
Cupping is a suction therapy applied to the skin may be used to stimulate tissue stagnation. 

I understand that acupuncture treatments in the state of Arizona are not a primary health care modality. I understand that seeing an ​acupuncturist for treatment does not replace seeing my primary care physician. I understand that if I am referred by my primary care physician for acupuncture, I will return to my primary care physician for follow up as needed.  
If my practitioner is a naturopathic doctor, they may act at my request, as my primary care physician who is also licensed to perform acupuncture. 
I understand that Chinese herbal formulas are not regulated in the state of Arizona and that under rare circumstances people experience certain side effects from the herbs. I will take the herbal formulas as directed and contact my practitioner if I experience any concerning side-effects. I will inform my practitioner if I am pregnant, have a cardiac peacemaker or other implanted electronic device or skin condition that may contraindicate acupuncture as a treatment therapy. 

The Benefits: I understand that I will be receiving acupuncture for the treatment of my health condition. I understand that the potential benefits of acupuncture include drugless relief of my symptoms and an improved state of health. 

The Risks
  Pain at site of insertion 
  Local burning 
  Fainting or dizziness 
  Broken needles 
  Local infection 
  Collapsed lung if needling in the near lungs 
  Spontaneous miscarriage 

Alternatives to Oriental Medicine Therapies 
There are reasonable alternatives to Oriental Medicine Therapies within naturopathy and within conventional medical care appropriate to my condition. I have discussed these alternatives with my provider. I have read this Consent Form and have had my questions answered about potential benefits, risks; and alternatives to my satisfaction and consent to treatment.  


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