I am enrolling in the Lyme treatment program and I clearly understand that the payment made for a slot in this program is non-refundable, even if I am unable to complete the full course of treatments that I sign up for.*

I understand that results are not guaranteed. I understand that Dr. Browne's past success rate is approximately 85% and that I may be one of the 15% who is unable to clear the Lyme infection using this protocol.*

I understand that the treatment schedule cannot be altered by me and that no treatments will be rescheduled unless, in the unlikely event that Dr. Browne is unable to provide the treatment due to illness or other life disruptions, or other "acts of God" such as weather disruptions occur, the session schedule will be extended and make-up days assigned.*

I accept that Dr. Browne has provided links to an overview of how Chinese medicine works on this website, but she will not be able to explain how Chinese medicine works verbally in the clinic.*

I have reviewed the information on how to prepare for my treatment provided on this website.*

I attest that I have no known allergies to herbs, mushrooms, or essential oils. I am able to consume alcohol-based tinctures.*

I hereby request and consent to the performance of herbal counseling, acupuncture treatments, and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for who I am legally responsible) by the acupuncturist Dr. Catherine Browne, DAOM, L.Ac.*

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tiu-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling.*

I understand that the herbal remedies may need to be prepared and the tinctures consumed may be an unpleasant smell or taste. I will immediately notify a member of clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.*

I understand 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).*

I understand that infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment, and that burns and/or scarring are a potential risk of moxibustion and cupping.*

The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine; however, some may be toxic in large doses, and some herbs may be inappropriate during pregnancy.*

I do not expect Dr. Browne to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on her to exercise judgment during treatment, which she thinks at the time, based upon the facts then known, is in my best interest.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent and that I will be responsible for transferring my patient records to a third party by personally picking up my records at a cost of $2 per page.*

I am not pregnant and do not plan on becoming pregnant during the course of this treatment. I will notify Dr. Browne immediately suspect that I have become pregnant.*

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.*

I declare that the info I’ve provided is accurate and complete.*