Informed consent form

The purpose of this form is for you, the patient to know how the information that you provide is treated and held, the parameters within which the practitioner works and clarity in terms of you providing consent to treatment.

 

*Any information I provide to my practitioner will be held in the strictest of professional confidence and used only for my treatments. If my case is used for any research or teaching I understand that all personal identifiers, such as (but not limited to) my name, address or profession will be removed. I understand and agree to my practitioner will hold my contact details and use them to get in touch with me.

 

*I may ask for any information to allow me to understand any treatment I am offered, and that my practitioner will inform me beforehand if a new treatment is to be used.

 

*I understand that if I am deemed to be under the influence of drugs or alcohol I may be refused treatment.

 

*I understand that the practitioner will use traditional Chinese diagnosis and will continue to fine tune my treatment throughout each session and each treatment is not necessarily the same.

 

*I understand that the practitioner has the right to refuse me treatment for any reason, e.g. if it is felt that my medical condition requires onward referral.

 

*My practitioner will give me explanations as to any areas of my body that I may need to expose for treatment, and without coercion or pressure offered sufficient time to decline treatment should I so wish.

 

*I understand the nature of physical contact in the healing sessions and I understand that I may withdraw my consent for any procedure, treatment, or the use of any of my personal information at any time without the need to explain my decision.

 

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.

 

Medical Disclaimer

Any information or guidance we provide is not a substitute for the consultation, diagnosis, and/or medical treatment of your doctor or healthcare provider. You must not rely on any information or guidance we provide you with as an alternative to medical advice from your doctor or healthcare provide and we expressly disclaim all responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered by you or any third party as a result of your reliance on any information or guidance we provide you with.

 

If you have any specific questions or concerns about any medical matter, you should consult your doctor or healthcare provider as soon as possible. If you think you may be suffering from any medical condition, you should seek immediate medical attention from your healthcare provider. Do not delay seeking medical advice, disregard medical advice or discontinue medical treatment because of information or guidance we provide you with. Nothing in this disclaimer will limit or exclude any liability that may not be limited or excluded by applicable law.

 

Declaration:

I understand that the information and healing sessions provided are not intended to be a replacement for medical treatment and clients are advised to of always consulted with a qualified GP or consultant before adopting any of the suggestions or taking part in the healing sessions provided.

 

*I confirm that I have read and understand all of the above, I have had my proposed treatment explained to me, I understand what procedures will be used, and I give my consent to be treated in this manner.

 

I agree and sign below that the information I have provided is correct and that I have not withheld any information about any medical condition and that to the best of my knowledge I am fit to receive a therapeutic treatment which may include acupuncture and related procedures. I will inform my practitioner when and if there are any changes to my health or medications or if I have received any other treatments or procedures, or I feel that there is any doubt as to whether I should receive treatment.

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I hereby understand that by its very nature, acupuncture and other forms of Chinese medicine, (including, but not exclusive to, acupuncture, acupressure, massage, herbs, aromatherapy, direct and indirect moxibustion, cupping, and electrical stimulation), may cause minor discomfort and may irritate the skin or leave a mark, puncture of the skin, bruise, or burn.

 

Whilst many people have reported physical and/or emotional benefits from attending healing sessions, I acknowledge that no claims, promises, or guarantees are being made as to the results and effectiveness of any treatment and therefore accept full responsibility for the outcome of said treatment. I understand that the practitioner cannot be held responsible or liable for any adverse side effects or reactions that may occur as a result of receiving acupuncture.

 

Patient's signature _______________________ (If under 16 years, parent/carer signature)

 

If over 12 years old and under 16 years old and attending without parental consent, Gillick Competence is to be considered. (See AAC Guidelines for Treating Under 18s.)

 

Print name _________________________________ Date: _____/_____/_______

 

Name of Patient if not the signatory ________________________________________