1. 本人提供的信息是完整和准确的，并无隐瞒可能影响治疗安全性的事实。I acknowledge that information given by me is complete and accurate to the best of my knowledge and that no fact that is likely to influence the safety of the treatment(s) that I have signed up for have been withheld.
2. 本人征求及同意接受注册中医师所推荐的中医外治治疗方案，包括针刺、灸法、手法治疗、电针、温灯照射、穴位按摩、拔罐、刮痧、激光针灸、热敏灸等等。I hereby request and consent to the performance of TCM external treatments as recommended by the registered TCM Practitioner, including acupuncture, moxibustion, TCM manipulation, electroacupuncture, heat-lamp therapy, acupoint massage, cupping, scrapping, laser acupuncture, heat-sensitive moxibustion.
3. 本人经注册中医师解释并了解以上治疗时或延后有可能出现，出血、瘀血、肿痛、皮肤红晕、小水泡、眩晕、惊厥、烧伤、烫伤、滞针、弯针、断针、气胸等状况。I have been informed and understand the possible risks and complications that may arise during or after the above-said treatment, including but not limited to bleeding, bruising, swelling, pain, skin redness, small blisters, fainting/dizziness, convulsions, burnt, scald, stuck, bent or broken needle, pneumothorax.
4. 本人深切了解并不期望注册中医师能预知并解释所有的治疗风险及预后状况。I understand that the registered TCM Practitioner may not be able to anticipate and explain to me each and every possible risk and complication of the above-said treatments.
5. 本人应向注册中医师探询所有有关治疗及预后的疑问。I understand that should I have any doubt or query, I may ask the registered TCM Practitioner for more information on the above-said TCM treatments and their possible risks and complications.
本人确定所提供的信息准确，本人已阅读并理解以上条文，本人谨此同意并授权进行治疗。I declare that the above information provided by me are true and to the best of my knowledge. I have carefully read and understood all the above information. I hereby give my permission and consent to the treatment/s.