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Customer Registration Form
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'Dr Liu Chinese Medicine Clinic' specialises in traditional Chinese medicines, traditional and modem acupuncture, acupressure (without needles), and other natural Chinese therapies, including cupping and moxibustion. The treatment is carried out by fully qualified and experienced practitioners in the case of acupuncture treatment. Only pre-sterilised and disposable needles are used to guarantee complete safety. I agree to undergo such treatment as proposed by the qualified practitioners at 'Dr Liu Chinese Medicine Clinic' and acknowledge the refund policy. I understand that my practitioners will try their best to achieve the maximum results, I understand that Chinese medicine treatment is an alternative medicine and complementary treatment and cannot be used as a substitute for the advice, diagnosis, and treatment of patients' health and disease conditions by medical institutions. In the event of a medical emergency, please call for help from the hospital immediately.
Would you like our staff contact with you by E-mil or text to track your recovery within 3-5 days of your visit by E-mail or text?
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No
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Consent Form for Traditional Chinese Medicine Treatment
Practitioner Information: Name:
Yuping Liu
License Number:
MACS2686
Clinic Address: 9 Eccleston Street, Belgravia, Londo n, SW1W 9LX (Light Centre Belgravia)
Introduction:
1. Acupuncture is recognized as a complementary therapy in the UK and is often used alongside conventional medical treatments. It involves the insertion of fine needles into specific points on the body to promote healing and improve well-being. While acupuncture is generally safe when performed by a qualified practitioner, it is important to be aware of the possible complications and side effects. Our clinic has informed the patient clearly about the possible scenarios before performing acupuncture treatment, which may include:
➤ Fainting: Due to the patient's special physical condition, fear of needles, or an empty stomach, fainting may occur during the acupuncture process.
➤ Pneumothorax: There is a risk of pneumothorax, which could be life-threatening, especially when acupuncture is performed on the chest or back area.
➤ Stuck Needle: Due to the patient's mental tension or body position change, a needle may get stuck during the acupuncture process.
➤ Hematoma: As acupuncture is a minimally invasive procedure, it may cause local swelling, bruising, or even bleeding at the needle site.
➤ Post-acupuncture Sensation: Due to the patient's physical condition and the nature of the acupuncture treatment, post-acupuncture sensations like soreness, heaviness, or numbness may occur.
➤ Skin Reaction to Moxibustion: A localized skin reaction, such as redness or blisters, may occur due to the patient's physical condition during moxibustion therapy.
➤ Skin Reaction to Cupping: Special physical conditions or skin sensitivity may cause blistering, bruising, or even bleeding during or after cupping therapy.
➤ Electrical Acupuncture: Using electrical devices in acupuncture may lead to numbness or discomfort due to electric currents.
2. Traditional Chinese medicine
➤ Allergic reactions: Some patients may be allergic to certain herbs and experience allergic symptoms such as rash, itching, and difficulty breathing.
➤ Gastrointestinal discomfort: Traditional Chinese medicine may cause gastrointestinal discomfort such as stomach pain, diarrhea, and nausea.
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➤ Toxic and side effects: Certain traditional Chinese medicines may have
toxic side effects on the liver, kidneys and other organs when used in high
doses or for long periods of time.
I authorized representative confirm that I have read and fully understand
the above-mentioned points and potential discomforts associated with
acupuncture,traditional Chinese medicine and massage treatment.
I am willing to accept acupuncture, traditional Chinese medicine,
massage treatment under the guidance of a licensed Chinese Medicine
Practioner, understanding the potential risks and benefits.
Consent Statement: I undersigned and consent to the treatments provided by
the practitioner named above. I have been informed about the procedure, its
risks, and benefits, including the possible adverse effects mentioned above. I
understand that acupuncture is a form of traditional Chinese medicine and
involves inserting fine needles into specific points on the body.
I acknowledge and confirm the following:
1. I have disclosed my complete medical history and any current
medications or conditions.
2. I understand that there may be some risk of minor discomfort, bruising,
bleeding, or other adverse effects.
3. I have had the opportunity to ask questions and discuss any concerns
with the practitioner.
4. I am aware that no guarantees have been made regarding the outcome
of the treatment.
5. I agree to follow the practitioner's instructions during and after the
treatment.
Patient Signature:
Date:
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Practitioner Signature: Tuping Lin
Date:
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