Online Consultation Form

Patient Informed Consent:
1. I hereby request and consent to be treated by acupuncture and/or Chinese Herbs administered by Miriam Tamara, hereinafter referred to as "Practitioner”.

2. I understand that acupuncture is performed by the insertion of fine, sterile disposable acupuncture needles (with or without the addition of electric current) through the skin, or the application of heat to the skin, or both, at certain points on the body, in an attempt to improve the body function and/or relieve pain.

3. I acknowledge that, although rare, certain side effects may result from acupuncture. These can include bruising, mild pain or discomfort, a feeling of weakness, fainting, nausea, and a temporary aggravation of symptoms. These effects are unusual and of short duration.

4. I accept that no guarantee is made concerning the use and effects of acupuncture or Chinese herbs.

5. I understand that I may stop treatment at any time.

6. I understand that the evaluation given me is an energetic assessment based on the acupuncture channel system. When statements are made regarding the state of various "organs", such as the heart, liver, kidneys, etc., they refer to the energetics of the acupuncture channels of the same name.

7. I acknowledge that Practitioner is not a western-trained medical doctor and does not advise on the use of medically prescribed pharmaceuticals or medical treatment, nor does he give any substances by injection.

8. I acknowledge that Practitioner is National Board Certified (NCCAOM) and a Licensed Acupuncturist (L.Ac.) in the state of Illinois.

9. I understand that the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
Online Consultation Form

Chinese Medicine: Acupuncture, Herbs and Bodywork
