What is/are your main complaint(s)?
I hereby request and consent to the performance of acupuncture treatment, massage treatment, manual therapy and other related procedures, including physical examinations, the use of acupuncture needles and modalities of heat (moxibustion), massage on myself (or the patient named below, for whom I am legally responsible). Though treatments and therapies are usually beneficial and seldom cause any problems at all, I understand and am informed that as with any medical treatments there are risks involved.