The following information is important for you to know prior to requesting an appointment with Michael Broffman, LAc. To sign this form electronically, click here.
Click here for our Privacy Policy, Notice of HIPAA Privacy Practices, Electronic Mail Consent, and Terms of Service.
MICHAEL BROFFMAN, LAc, IS A LICENSED ACUPUNCTIRST
Michael Broffman, LAc, is a Licensed Acupuncturist (LAc). Michael Broffman, LAc, is not a medical doctor.He does not claim to diagnose, treat, cure, or prevent any medical conditions or pathologies, nor prescribe medicine, nor in any way represent himself as so doing. His services cannot replace those of a licensed physician. For any medical condition, you are advised to seek care from an appropriate medical practitioner. Whether you choose to engage a medical practitioner or not to assist you in your care is your right and Michael Broffman, LAc, assumes no responsibility for your decision in this matter.
ALWAYS CONSULT YOUR DOCTOR
Michael Broffman, LAc, provides services that are only intended to support the efforts of your doctor; any herbs, supplements, treatments, information, recommendations, or suggestions provided must be reviewed with and approved by your doctor.
INFORMATION IS FOR REFERENCE ONLY
Michael Broffman, LAc, or other staff may give you information about herbs, medicine, and treatments that you may wish to investigate, including information about modalities, treatments, and drugs that are outside the scope of practice for a Licensed Acupuncturist. Our giving you this information is purely for your reference and it is your responsibility to thoroughly investigate this information and review it with your doctor to determine if it’s appropriate for you.
PEOPLE WITH CANCER AND OTHER SERIOUS DISEASES
Michael Broffman, LAc, does not diagnose, treat, alleviate, or cure cancer or other serious diseases. He can, however, work with people diagnosed with cancer and other serious diseases in order to relieve the side effects of or protect the body from the damaging effect of the therapies used to treat those diseases so long as that work does not counteract the efficacy of or otherwise interfere with the treatments prescribed for the patient by their doctor.
ABOUT ACUPUNCTURE & OTHER RELATED TREATMENTS
I request and consent to the performance of acupuncture treatments and other related procedures on me by Michael Broffman, LAc. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, massage, herbal medicine, vitamins and nutritional supplements, and nutritional counseling.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although Michael Broffman, LAc, only uses single-use sterile disposable needles as per California State law and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment, which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.
CALIFORNIA STATE ACUPUNCTURE BOARD
The practice of acupuncture is regulated by the California State Acupuncture Board: 1747 N. Market Blvd, Suite 180, Sacramento, CA, 95834. Phone: 916-515-5200. Email: acupuncture@dca.ca.gov.
EMERGENCY SERVICES
Michael Broffman, LAc, and Pine Street Clinic, LLC, does not provide urgent or emergency service. If you have a medical emergency, call 911 or go to your nearest emergency room immediately.
HIPAA PRIVACY NOTICE
Click here for details how medical information about you may be used and disclosed and how you can get access to this information.
FDA DISCLAIMER ABOUT HERBS & SUPPLEMENTS
Statements may be made about herbs and supplements. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
INFORMED CONSENT
I, the undersigned, assume all responsibility for decisions I make regarding my health, recognizing that (a) Michael Broffman, LAc, is not a medical doctor, (b) no claims are made that his services, including acupuncture, herbal, nutritional recommendations, can treat or cure any medical condition, (c) all suggestions and recommendations are provided for informational purposes only and must be reviewed with and approved by my doctor, (d) there is no implied or stated guarantee of success or effectiveness of any specific recommendation, and (e) I am free to act upon or disregard the recommendations of Michael Broffman, LAc, as I so choose.
I hereby release Michael Broffman, LAc, and Pine Street Clinic, LLC, from all responsibility for my actions and any consequences thereof in the present time and in the future with no constraints. I hereby affirm that I consent and agree to the above statements of my own free will and request to engage in the services offered by Michael Broffman, LAc and participate in a professional relationship with him pursuant to the statements herein.
Acknowledged and agreed:
Sign Name:
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Print Name:
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Today’s Date:
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