Document 6571100

Joseph Tokaruk M.D., F A C E , F.R.C.P. [C],
Board Certified in Endocrinology, Diabetes, and Metabolism,
Dipiomate American Board of Lipidology,
Specialist in Clinical Hypertension,
Associate Member American Academy of Medical Acupuncture
Please read this information carefully, and ask your practitioner if there is anything you do not understand.
What is acupuncture?
Acupuncture is a form of therapy in which single-use, sterile, disposable, fine needles are
inserted into specific points on the body. The needles are inserted through the skin, into
underlying muscles and tissues at specific points on the body for the purpose of alleviating pain,
relieving pressure on nerves, improving mobility, and re-establishing normal function.
Is acupuncture safe?
Acupuncture is generally very safe. Serious side effects are very rare - less than one per 10,000
treatments.
Does acupuncture have side effects?
You need to be aware that:
Drowsiness occurs after treatment in a small number of patients, and, if affected, you
are advised not to drive;
Minor bleeding or bruising occurs after acupuncture in about 3% of treatments;
Pain during treatment occurs in about 1% of treatments;
Existing symptoms can get worse after treatment (less than 3% of patients). You should
tell Dr. Tokaruk about this, but it is usually a good sign.
i, the undersigned, do hereby give my voluntary consent for the administration of medical
acupuncture and other ancillary techniques as necessary, including dry-needling, cupping,
and/or electro-acupuncture as deemed appropriate by Dr. Joseph Tokaruk.
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Electro-acupuncture - where the needles are electrically stimulated at various
frequencies to increase the therapeutic benefit
Dry needling - where muscles are briefly needled by acupuncture needle, held in a
needle holder, to release trigger points and spasms.
Cupping - where suction cups are applied to specific points or regions of the body.
I understand and am informed that in the practice of acupuncture there are some risks to
treatment, including, but not limited to, minor bleeding or bruising, minor pain or soreness,
nausea, fainting, infection, shock, convulsions, possible perforation of internal organs, and
stuck or bent needles. Needling on the chest area can result in pneumothorax or
hemopericardium. 1 can refuse treatment to the chest area A pneumothorax is a collapsed
lung. Pneumothorax occurs when air leaks into the space between your lungs and chest wall.
This air pushes on the outside of your lung and makes it collapse. In most cases, only a portion
of the lung collapses. A small, uncomplicated pneumothorax may quickly heal on its own. When
the pneumothorax is larger, doctors usually insert a flexible tube or needle between your ribs
to remove the excess air. Hemopericardium is blood in the pericardial cavity.
I further state that the following DO NOT exist in my current state of health and I will
immediately notify the practitioner of any changes:
>Pregnancy
>Local Infections
>Pacemaker or other implants
>Bleeding disorders
>Elevated risk of infection
>Anticoagulants (e.g. Coumadin)
I understand that the services I will be receiving are only related to acupuncture. 1 understand
that Dr. Joseph Tokaruk is a medical doctor, specialist board certified endocrinologist.
However, he will not prescribe medication, complete forms, or perform the functions of a
primary care physician for me. I understand that no narcotics will be ordered. All medications
as prescribed by other physicians will be continued as instructed by those doctors.
My Primary Care Physician is
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A medical consultation for management of chronic medical problems will require a referral
from a health care provider before endocrine medication and endocrine disease management
can start. This consultation is at a separate appointment and may be covered by insurance. A
visit for acupuncture alone does not Include a consultation for endocrine problems. We will be
happy to contact your primary care provider to get such a referral for a consultation for
endocrine problems.
Acupuncture is generally not covered by medical insurance and considered an elective
therapeutic treatment. Established patients of Dr J. Tokaruk (those patients seen within the last
year for endocrine problems) can have both acupuncture and medical management of
endocrine problems without a new referral from a primary care health provider. A discount is
also given.
I have read the above consent form. I have also had an opportunity to ask questions about its
content and by signing below I agree to the above mentioned acupuncture procedures. I intend
this consent form to cover the entire course of treatment for my present and future conditions
for which 1 seek treatment.
Print Patient's Name
Signature of Patient
Date
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Exclusion of Patients on Anticoagulants
If you take ANY of the following medications, you cannot receive acupuncture therapy. Please
carefully review the following list.
Warfarin
Coumadin
Jantoven
Arixtra
Enoxaparin
Fondaparinux
Fragmin
Love n ox
Xarelto
Angiomax
Heparin
Argatroban
Eliquis (aplxaban)
I certify that I have given a complete and up-to-date list of my medications and DO NOT take
any of the medications listed above.
Patient's Signature
Date
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