Informed Consent Statement

I am allowing Clinton M. Smith, D.C. to assist me in smoking and/or tobacco dependence cessation. I have read all the documents contained in the web site or presented to me in the office and understand them fully.

I understand there are no implied or written guarantees that my dependence will be temporarily or permanently resolved. I acknowledge and understand that acupuncture is an art form of healing and that each needle used on my person is a one-time sterile use and is then discarded.

Though highly unlikely, it is understood that I have been advised that a low- grade infection could occur from acupuncture and if left untreated could cause permanent injury or even death. There may be also some slight bleeding upon removal of the needles.

I do not hold Dr. Clinton M. Smith or his staff responsible for injury or outcomes resulting from this program.  I also acknowledge that I have read and understand the documents on this web site and/or provided to me by Dr. Smith, explaining this program.

Signed:________________________

Date:__________________

Witness:_______________________

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