Informed Consent Injection Therapy

Erica Boulangée M.Ac, L.Ac, LMT

Injection Therapy:

Whenever a needle is introduced though the skin, inherent risks are present. Although the risks are small, the expected benefit from the procedure must outweigh the possible risks. Make sure that you have a thorough understanding of the expected benefit from the injection. The risks of injection depend on where the injection is made and what is being injected. If the injection is made in a large muscle, the risk of hitting vital structures is very small. Injections in the area of neurovascular bundles (where nerves, veins, and arteries travel together) have a higher risk of injury, and injections in the area of the lung organs have a higher risk of injuring them.

The risks of injection are:

  1. Infection: With current standard procedure of sterile needles and antiseptic technique, this risk is very small, but it still exists. Redness and swelling are the early signs of infection. Any redness or swelling should be reported immediately to avoid the more serious complications of sepsis (bacteria in the blood stream) or osteomyelitis (infection of the bone).
  2. Puncture of nerves, arteries, or veins: This risk varies greatly on the area of injection. When acupuncture point injections are made in the body of large muscles, this risk is very small. In other areas where these structures are larger and running together, the risk is increased. A nerve may be permanently damaged or bleeding/bruising may occur with puncture of a vein or artery.
  3. Puncture of a lung or vital organ: Injections in the area of the chest could puncture a lung in which the serious complication of a tension pneumothorax could occur. In this condition the lung leaks air into the lung cavity progressively compressing the heart and lung. The person becomes short of breath, which can advance to death if untreated. Puncture of other vital organs is extremely unlikely and depends on the site of injection.
  4. Allergic reaction to injected substance: Allergic reactions to homeopathic substances have not been reported, and, in fact, they are used to treat allergic conditions. However, the possibility still exists. An allergic reaction is usually hives, but a lung reaction could occur with severe shortness of breath, or the most serious reaction of anaphylaxis. In anaphylaxis there is the acute onset of shock, and this is a serious life-threatening emergency that could result in death.
  5. Injections for Cosmetic reasons carry the same above listed risks as injections done for non-Cosmetic reasons. Cosmetic injections are done in acupuncture points that traditionally strengthen the shen (the vitality shown in the face). Results, if any, are never guaranteed.


I hereby request and consent to injection therapy on my body, in order to enhance the effect of stimulating an acupuncture point. I understand that I will only be injected with substances that fall within the scope of practice of Licensed Acupuncturists in Colorado. I understand the risks involved. I do not expect my practitioner to be able to anticipate all risks and complications. By signing this form, I agree to accept all risks and release all liabilities from Erica Boulangée L.Ac., her apprentices, and Beyond Massage Inc.

I have read and understand this document

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Document name: Informed Consent Injection Therapy
Unique Document ID: 3a0a716b7c57c84b83b149587ef4e3f44cb83076
Timestamp Audit
November 30, 2017 9:15 pm MDTInformed Consent Injection Therapy Uploaded by Erica Boulangée - [email protected] IP
November 30, 2017 9:19 pm MDTErica Boulangee - [email protected] added by Kyle Gordon - [email protected] as a CC'd Recipient Ip:
December 6, 2017 1:36 pm MDTErica Boulangee - [email protected] added by Erica Boulangee - [email protected] as a CC'd Recipient Ip:
December 22, 2017 10:59 am MDTErica Boulangee - [email protected] added by Erica Boulangée - [email protected] as a CC'd Recipient Ip: