630-236-8600 / 630-708-2225   |   Telehealth Now Available


Paperwork must be completed prior to your visit so we can spend your scheduled appointment time completing your exam and answering any questions/concerns you may have. If you do not have access to a printer, please arrive 15 minutes prior to your appointment to complete these forms at our office. We look forward to meeting you!

Please click DOWNLOAD to complete your acupuncture paperwork. Feel free to contact us if you have any questions.

Complete the pdf forms and save the file on your computer. Print all forms and sign where applicable. Bring your completed forms with you to your scheduled appointment along with your insurance information.

Informed Consent Regarding Treatment

Welcome, we appreciate your trust and the opportunity to be of service to you. We enter this relationship with optimism and an eagerness to work with you. Because treatment is a collaborative effort, we will work with most productively and comfortably together when we mutually agree upon and understand the nature of the treatment experience. This set of agreements is designed for you to have informed consent regarding your treatment. Please feel free to note questions which come to mind so we can discuss them.

Myofascial Therapy

Participating in Participating in Myofascial Therapy (acupuncture, guasha, cupping and moxa) can result in a number of benefits to you, including neurological, musculoskeletal, visceral and emotional changes. Working towards these benefits, however, requires effort and can result in discomfort. Change will sometimes be easy and quick or sometimes will be slow and frustrating. It is also possible that there may be times when treatment produces no discernible benefits or change.

  • Bruising, tenderness and discoloration may occur in some cases. Post treatment stiffness is often present and can be relieved by exercises you will be given. Appropriate nutrition to assist the treatment process will be recommended as needed.
  • Some patients will have emotional reactions. These are associated with recalling feelings from a past event as they are being moved out of the tissues. This can simply be exact memories about the details of the trauma incidents, to the more rare (and severe) reactions that are reliving some traumatic event (less than one out of fifty emotional reactions). Remember that these emotional reactions may happen with any treatment.
  • Cupping could potentially result in circular discolorations of skin ranging from light red to dark purple up to one week after treatment.

Instrument (Graston/Guasha) Technique, Acupuncture, Cupping, Guasha and Moxa Questionnaire and Informed Consent

Please answer the following questions. Read the statements concerning the technique and sign below. If you have any questions, please speak with your clinician.

Instrument Assisted Massage (IAM) is an instrument assisted variation or traditional cross fiber or transverse friction massage. The instruments consist of stainless steel tools of various sizes and contours. The form of treatment is used to "break up" or "soften" scar tissue, thus allowing for the return of normal function in the area being treated.


Acupuncture can enhance energetic pathways in the body, leading to physical, musculoskeletal, emotional, neurological wellness. Acupuncture can help patients with various imbalances including; regulation of emotions, improved well-being, fertility, migraines, ease joint and muscles pain and stiffness and a variety of other issues as well. Process usually is about 30 minutes per treatment. Electrical stimulation may be used.

*Note: Acupuncture needles are single-use, disposable stainless steel of various lengths and thickness (gauges).
*Note: Cupping – uses solid glass jars, use of fire to create suction against skin (note: fire does not touch the patient). Cupping is a combination of sliding along the body and sitting on affected area for a couple minutes.
*Note: Electrical stimulation is a therapy used to enhance an acupuncture treatment by providing increased stimulation to the needles. Electrodes are attached to a pair of needles to pass a small electrical current between them. It is not recommended for patients with pacemakers or surgical implants.

All of the above techniques may produce the following:
  • Local discomfort during the treatment.
  • Reddening of the skin.
  • Superficial tissue bruising.
  • Acupuncture may cause minor bleeding.
  • Post treatment soreness.
  • Low-risk of needle breaking while in patient, due to sudden movement, muscle contraction.
  • (Cupping) Soreness during/after treatment, circular light red-dark purple discoloration at affected site up to one week, bruising and low-risk of burns or blisters.

All of the above techniques is designed to minimize discomfort; however the above reactions are normal, and in some instances unavoidable.

All of the above techniques have several components. Your clinician will determine the protocol for you.

  • Warm up of the treatment area.
  • Technique Instrument Assisted Soft-Tissue Manipulation.
  • High repetition, low load exercise.
  • One to three 30-second stretches.
  • Low Repetition, high weight exercise.
  • Hydrotherapy (Ice/Heat).
  • (Stretching/Rehabilitation exercise.

All components of Graston, Acupuncture, Cupping and Moxa Techniques have been explained to me. I understand the risks of the procedure and I give my full consent for treatment.

Need consultation

Quick Appointment Request

Contact our customer support team if you have any further questions. We are here to help.

Start Here