I acknowledge that Natural Endocrinology Specialists (NES) has discussed with me the medical basis for acupuncture/TCM in my case and has discussed the risks and benefits of this therapy with me. I understand that I have the right to a second opinion and to secure other opinions about my circumstances and healthcare as I see fit.

I hereby consent to treatment by acupuncture/TCM and certify that I understand the nature of this treatment, including the risks of possible complications and choices I may have about other approaches. I have been adequately informed, questions I have asked have been satisfactorily answered, and I have executed this consent voluntarily and of my own choice. I have not been offered any guarantee as to the outcome. I have given my provider at NES all of the information they need to make treatment decisions in my case.

I represent that I am seeking treatment in order to further my own health and for no other reason. I do not represent a third party. I acknowledge receipt of a copy of this consent should I request it.