Paediatric Acupuncture Intake Form

Surgeries, major procedures, major illness and/or hospitalizations and dates.
Please list all medication(s) and reason for taking.
Allergies/Sensitivities (food, drugs, or environmental) Latex, Fragrance, Seasonal, Other (please list)
Major diseases that run in your family

Paediatric Acupuncture Consent to treat
Name

First NameLast Name
I(Parent/Guardian) First &last name hereby agree and consent to performance of acupuncture and/or other procedures on First and last name
By signing the below, you are acknowledging that you have read and accepted this Data Protection Policy & Cancellation Policy and give consent to the practitioner to maintain records for the purpose outlined within the policy, as
well as use your contact details to keep in touch.Herby agree and consent to the performance of acupuncture Last Name
By signing below you agree for First &last nameto have a treatment and with the above Data protection and Cancellation Policy.
Parent or Guardian Name:*
Parent's Signature
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Rows	Yes	No
Cough
Shortness of breath or difficulty breathing
Temperature of over 38C or feeling feverish, chills or shivering
Sore Throat
Flu like symptoms, such as fatigue, headache
Nausea or diarhoea
New loss of taste or smell

Paediatric Acupuncture Intake