Acupuncture Sound Bath Consent Form
1. Description of Services
You are consenting to receive a therapeutic Acupuncture Sound Bath, a holistic experience that
integrates acupuncture, a licensed healthcare modality, with complementary sound healing
practices. Your session may include:
• Insertion of sterile, single-use acupuncture needles at specific points
• Optional ear seeds, auricular therapy, or non-insertive techniques (e.g. acupressure)
• Use of sound-based tools such as tuning forks, singing bowls, gongs, etc.
• Guided breathing, meditation, or visualization techniques for deep relaxation
Acupuncture will be provided in accordance with Traditional Chinese Medicine (TCM)
principles. Sound healing is offered separately as a complementary, non-medical wellness
practice.
2. Purpose and Scope of Treatment
Acupuncture aims to support the balance of bio-physiological function and assist in physical,
emotional, and spiritual well-being.
Sound healing offered in this setting is not licensed or regulated by the California Acupuncture
Board. It is not intended to diagnose or treat any condition, and is provided solely as a
relaxation-based, meditative experience that may support emotional balance and well-being.
3. Risks and Possible Side Effects
You may experience temporary effects, including:
• Minor soreness, bleeding, or bruising at needle sites
• Dizziness or lightheadedness
• Emotional release, fatigue, or mild discomfort
• Sensitivity to sound or vibration
All instruments are cleaned and used with care, and all acupuncture needles are sterile and
single-use. Please notify the practitioner immediately if you experience discomfort.
4. Contraindications and Communication
Please inform the practitioner if you:
• Are pregnant or planning to become pregnant
• Have a pacemaker or implanted medical device
• Have a seizure disorder or sound sensitivity
• Are under the influence of alcohol or recreational drugs
• Have a serious medical condition or communicable illness
Open communication ensures your safety and enhances the experience. You may decline or opt out of any part of the session at any time.
5. Practitioner Information
Practitioner Name: Andrew W. Barretto, L.Ac., DACM
CA License Number: AC 19820
NPI Number: 1669244919
Business Name: Acupuncture Works Prof. Corp. ; FBN Integration Clinic / Original Qi Club
Contact: 213-573-5110 ; drew@integration.clinic
Acupuncture is performed by a licensed acupuncturist under the laws and regulations of the
California Acupuncture Board.
Sound healing services are offered as a complementary, non-licensed modality, separate from
acupuncture treatment.
6. Acknowledgment and Voluntary Consent
By signing below, you acknowledge and agree to the following:
• I have read and understood the information above.
• I voluntarily consent to receive acupuncture and complementary sound healing services.
• I understand that sound healing is not a licensed medical treatment and is not part of the
scope of acupuncture practice.
• I have had the opportunity to ask questions and all of my questions have been answered
to my satisfaction.
• I understand that I may stop the session or decline any part of the treatment at any time.