{"id":7923,"date":"2025-11-19T17:30:09","date_gmt":"2025-11-19T17:30:09","guid":{"rendered":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/?page_id=7923"},"modified":"2025-11-19T18:17:14","modified_gmt":"2025-11-19T18:17:14","slug":"acupuncture-consent-form","status":"publish","type":"page","link":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/acupuncture-consent-form\/","title":{"rendered":"Acupuncture Consent Form"},"content":{"rendered":"\n<p><style>\n   .form_addrres ul li{\n   justify-content: flex-end;\n   display: flex;\n   grid-gap: 10px;\n   margin-bottom: 2px;\n   }\n   .form_addrres ul li a{\n   color: #525252;\n   }\n   .form_icon_box i{\n   color: #f37423;\n   }\n   .border_class{\n   background: rgb(83,83,83);\n   background: -moz-linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\n   background: -webkit-linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\n   background: linear-gradient(90deg, rgba(83,83,83,1) 50%, rgba(243,116,35,1) 50%);\n   filter: progid:DXImageTransform.Microsoft.gradient(startColorstr=\"#535353\",endColorstr=\"#f37423\",GradientType=1);\n   height: 5px;\n   }\n<\/style><\/p>\n<section id=\"form_section\" class=\"my-3\">\n<div class=\"container\">\n<div class=\"row align-items-center\">\n<div class=\"col-6\">\n<div class=\"form_logo\"><img decoding=\"async\" class=\"img-fluid\" src=\"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-content\/themes\/gorewayphysio\/assets\/logo\/site-logo.png\" alt=\"logo\" width=\"270px\" \/><\/div>\n<\/div>\n<div class=\"col-6\">\n<div class=\"form_addrres\">\n <ul>\n                  <li>\n                     <a href=\"tel:+1 (905) 612-8222\">+1 (905) 612-8222<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-phone-flip\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"fax:+1 (905) 612-8752\">+1 (905) 612-8752<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-fax\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"mailto:gorewayphysio@gmail.com\">gorewayphysio@gmail.com<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-envelope\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"https:\/\/gorewayphysiotherapy.com\/\">https:\/\/gorewayphysiotherapy.com\/<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-globe\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"#\">7330 Goreway Drive, Unit 20\n                     Mississauga, ON L4T 4J2<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-location-dot\"><\/i><\/div>\n                  <\/li>\n               <\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<section class=\"border_class\"><\/section>\n<section id=\"service_details\" class=\"py-5\">\n<div class=\"container\">\n<div class=\"row\">\n<div class=\"col-12\">\n<h2 class=\"text-center\">CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION<\/h2>\n<h3 class=\"text-center\">Informed Consent for Acupuncture Care FORM &#8211; AC<\/h3>\n<br \/>\n<h4>Please Read Carefully<\/h4>\n<p>I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture, as necessary, including moxibustion, cupping, and\/or electroacupuncture by the above- named doctor or another duly authorized doctor in the clinic.<\/p>\n<p>I understand and am informed that in the practice of acupuncture there are some risks to treatment, including, but not limited to, minor bleeding or bruising, minor pain or soreness, nausea, fainting, infection, shock, convulsions, possible perforation of internal organs, and stuck or bent needles.<\/p>\n<p>I have been advised that only pre-sterilized needles will be used. All acupuncture needles are properly disposed of after each and every treatment.<\/p>\n<p>I do not expect the doctor to be able to anticipate and explain all possible risks and complications. I wish to rely on the doctor to exercise judgment during the course of the treatment which the doctor feels at the time, based upon the facts then known, is in my best interests. I understand that the results are not guaranteed.<\/p>\n<p>I have read this consent form. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above mentioned acupuncture procedures. I intend this consent form to cover the entire course of treatment for my present and future conditions for which I seek treatment.<\/p>\n<br \/>\n<h4>N.B. Female Patients:<\/h4>\n<p>I fully understand that in the case of pregnancy, a risk of causing fetal distress with acupuncture treatment(s) is possible. I hereby state that I am not pregnant, nor is there any possibility that I may be pregnant.<\/p>\n<h3 class=\"text-center\">READ BEFORE SIGNING<\/h3><\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7927-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"7927\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7923#wpcf7-f7927-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"7927\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7927-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"text-center\">\n\t<div class=\"form-row text-center\">\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-778\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" id=\"inputDate\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-778\" \/><\/span><br \/>\n<label for=\"inputEmail4\"><strong>Date Signed <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-558\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"inputPatentname\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-558\" \/><\/span><br \/>\n<label for=\"inputPassword4\"><strong>Print Patient\u2019s Name <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-764\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"inputPatentname2\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-764\" \/><\/span><br \/>\n<label for=\"inputAddress2\"><strong>Signature of Patient<br \/>\n(or parent\/guardian)<\/strong> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-lg-12\">\n\t\t<p><a href=\"\" target=\"_blank\"><button type=\"button\" class=\"btn btn-danger\">Download PDF<\/button><\/a><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-success\" type=\"submit\" value=\"Submit\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/section>\n","protected":false},"excerpt":{"rendered":"<p>+1 (905) 612-8222 +1 (905) 612-8752 gorewayphysio@gmail.com https:\/\/gorewayphysiotherapy.com\/ 7330 Goreway Drive, Unit 20 Mississauga, ON L4T 4J2 CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION Informed Consent for Acupuncture Care FORM &#8211; AC Please Read Carefully I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture, as necessary, including moxibustion, cupping, and\/or electroacupuncture [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7923","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7923","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/comments?post=7923"}],"version-history":[{"count":6,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7923\/revisions"}],"predecessor-version":[{"id":7931,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7923\/revisions\/7931"}],"wp:attachment":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/media?parent=7923"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}