New Patient Form - Acupuncture

Reason for visit

Please provide information regarding your reason for visit

Informed Consent

You have the right, as the patient, to be informed about your condition as diagnosed by your practitioner. This includes their assessment of the likelihood of success and the number of treatments that may be required. You also have a right to understand the nature of an acupuncture treatment and any adjunctive techniques that will be used: such as moxibustion, cupping, guasha and electro-acupuncture.

Acupuncture: involves insertion of fine needles at acupuncture points. There are hundreds of acupuncture points all over the body. The most commonly used are on the arms, below the elbow, and on the legs, below the knee.  It is best to wear loose fitting clothing but on occasions it may be necessary to remove items of clothing.

Moxibustion: involves the burning of the herb Chinese mugwort (Artemisia argyi), commonly known as moxa, to warm acupuncture points and areas of the body. There are different techniques such as placing the moxa on the handle of a needle, a moxa stick, placing moxa directly on the skin.

Cupping: A partial vacuum is created within cups which are placed on the skin. This produces a suction effect. The vacuum is produced either by fire (traditional method) or by a pump.

Guasha: The use of a smooth edge tool to repeated stroke the skin.

By its very nature, acupuncture and other forms of Chinese medicine may cause minor discomfort and may irritate the skin, leave a mark, bruise, or burn.

Confidentiality & Safeguarding

Your notes and all information about you will always remain confidential except in exceptional situations.  This is usually where the practitioner’s duty to society overrides their duty of confidentiality.  For example, if criminal or safeguarding issues arise, disclosure may be necessary.  Every effort will be made to discuss this with you.

I understand by signing this form I am giving written consent to treatment. I also understand that I am free to withdraw my consent at any time.

I understand that I must disclose my medical history, illnesses and medication to my practitioner, and update this as and when it changes. I understand that not doing this could increase the likelihood of adverse reactions.

If I do not turn up for my booked appointment or cancel within 24 hours of the appointment, I may be liable to pay the full fees for the appointment I have missed.