Intake Form

Full Name*

First NameLast Name

Is a Parent/Guardian filling out this form?

YesNo

Name of the Parent/Guardian

First NameLast Name

Relation to Child

Birth Date

Date

Gender

Email Address*

example@example.com

Phone Number

Area CodePhone Number

Emergency Contact

NamePhone Number

What is your main reason for booking?

Are you currently taking any medication (over the counter or prescription)?

YesNo

Please list medication below

Do you experience any condition or illness such as heart/blood pressure problems, epilepsy, blood/bleeding disorders, diabetes, allergies or are you aware of any particular risk of infection?

YesNo

Have ever had a fit, fainted or felt dizzy?

YesNo

Do you have a pacemaker or any other electrical implant?

YesNo

If ‘yes’, please describe below, add any other medical details that may be relevant.

Informed Consent

What is Acupuncture?

Acupuncture is a system of medicine that uses very fine, sterile, single-use needles to stimulate specific points on the body. It is a holistic form of treatment and may also include using techniques such as moxibustion, cupping, gua sha, pricking, massage and electro acupuncture, all of which will be explained by the practitioner.

Is Acupuncture Safe?

Extensive research has shown that reported adverse events following acupuncture are incredibly rare and that most side effects are mild and pass very quickly. Serious side-effects following acupuncture are uncommon with research showing that on average only 1 in 10,000 treatments results in a significant side effect.

The Most Common Side Effects

Side effects may include drowsiness, minor bruising or fainting but these are generally rare. All needles are sterilised and single use. This means the risk of infection is minimal. Sometimes aggravation of symptoms occur before improvement, this is usually a good sign. Most people feel pleasantly relaxed and experience no symptoms at all.

What to Expect

Your practitioner will take a full case history and perform any necessary examinations such as taking your pulse, looking at your tongue and palpating your abdomen. This provides your acupuncturist with the information they need to create an effective treatment plan that is tailored for you. This diagnosis is relevant whatever your health issues may be, as it informs your practitioner about the way your individual system works and how they can best help you.

Please make it known to the practitioner if you are uncomfortable with any part of this, and raise any concerns you have regarding any aspect of treatment on the day with the practitioner.

Appointment Preparation

For your comfort, please avoid attending your appointment on an empty stomach. To ensure modesty, we aim to minimise undressing as much as possible. However, certain treatments may require you to remove outer clothing, down to underwear or a bra. We recommend wearing loose-fitting clothing or bringing a pair of shorts if you prefer.

Payment Policy

We kindly ask for at least 24 hours’ notice if you need to cancel your appointment. Cancellations made with less than 24 hours’ notice will incur a charge for the full session fee. Thank you for your understanding.

Acknowledgement

By signing below, I confirm that I (or, if applicable, the minor child for whom I am the parent or legal guardian) consent to the above-named procedures. I intend this consent form to cover the entire course of treatment for my (or my child’s) present condition and for any future condition(s) for which treatment is sought at this clinic.

I understand that patient records and patient information will be kept confidential and shared only when necessary to provide care and services, by my authorisation, or when required or permitted by law.

Date*

Date

Signature*