Consent for OMM/OMT and or Medical Acupuncture Form

Hidalgo Integrative Medicine, PLLC

Consent form for Osteopathic Manipulative Medicine / Treatment (OMM/OMT ) and or Medical Acupuncture

Please read and understand the following information before signing this consent. If you have questions, I encourage you to ask questions concerning OMT/OMM and or Medical Acupuncture roles in your treatment for improved health.

What is Osteopathy?

What are the benefits of Osteopathy?

The benefits of osteopathic manipulation include reduction of pain or discomfort, restoration of symmetry, increase in strength and mobility, improvement and reduction in tingling and numbness, increase of the body’s natural healing mechanisms, reduction in swelling of tissue, and an return to the body’s homeostasis.

What are the potential side effects of OMM/OMT and or medical acupuncture?
OMM is usually well tolerated but some people can have adverse side effects, including:

Local pain and stiffness, general body aches and worsening of pain, headache, tiredness, lightheadedness, broken bone, disc herniation, and occlusion of a blood vessel.

Potential side effects of medical acupuncture could include:

Fainting, infection, bleeding, lung and other organ puncture, nerve damage, including spinal cord trauma, swelling, broken needles, or possible death.

I understand that by signing this document, I have read the above description concerning osteopathic manipulative treatment and or medical acupuncture and understand the above information concerning all aspects of OMM/OMT and or medical acupuncture potential side effects.

I acknowledge and understand the possible risks and benefits of osteopathic manipulative treatment and or medical acupuncture. I have informed Dr. Hidalgo of any previously diagnosed conditions that may affect the treatment outcome. I also understand that Dr. Renaldo Hidalgo will not be performing routine medical care for me and that this encounter does not replace routine medical care or take the place of your primary care provider. I also understand that Dr. Hidalgo will not be my primary care physician while working under the premise of Hidalgo Integrative Medicine, PLLC and that I must obtain routine acute and chronic medical care elsewhere. No guarantee has been made by anyone as to the results that may be obtained from osteopathic manual treatment procedure/s and or medical acupuncture. I voluntarily give my authorization and consent to the performance of osteopathic manipulative treatment and or medical acupuncture by Dr. Hidalgo.

With any area of medicine, other unexpected risks or complications may occur. If during the course of treatment, and unforeseen condition/s are discovered, it may be necessary to postpone or stop OMM/OMT and or medical acupuncture.

I also am aware that certain medications and social habits including drinking alcohol, using smoke or smokeless tobacco, marijuana, any steroid, and or narcotics can lessen the potential results of acupuncture/ OMM/OMT.

I hereby consent to such treatment and release Dr. Renaldo Hidalgo, DO from any and all claims of damages for injury which may result from such treatment. I have had the opportunity to ask questions, which have been answered to my satisfaction. The nature and consequences of the above treatment have been fully explained to me, and I am convinced that the treatment/s is/are in my best interest. I also confirm that no guarantee of results have been made to me. I know that I am seeking OMM/OMT and or medical acupuncture in order to further my own health and for no other reason. I am aware that I can withdraw this consent and stop treatment at any time.