Acupuncture New Client Form

Acupuncture New Client Form

Health and Wellness Acupuncture Form Preview
  • New Client Form

    The following questions relate to your current and previous health condition and will take less than 10 minutes to complete. Please ensure you complete all the fields marked with an asterisk *.

    All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *.


  • Client Medical History

    Please complete the following questionnaire to the best of your knowledge. Further questions may be asked by your practitioner regarding the information provided here.




  • Please check any symptoms that apply to you and use the Other category to add symptoms not listed.














  • Clinic Policies:

    Client services and chart information are confidential. Written authorization is required from you to release any information.  

    • Please turn off your mobile phone for optimal relaxation      

    • Your scheduled session is set aside for you. We do not double book appointments      

    • Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee 80%. Less than 24 hours notice will incur a cancellation fee of 100% of the scheduled fee       

    • You will have a consultation with your practitioner to discuss your session

    Client Agreement:

    I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.

    I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Integrative Health Chinese Medicine Centre and my practitioner from any liability whatsoever arising from failure on my part.

    Informed Consent to Treatment:

    I hereby agree and consent to the performance of acupuncture and other Traditional Chinese and Japanese Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In (Japanese massage), Shiatsu (Japanese massage), Chinese or western herbal medicine, lifestyle, exercise and nutritional counselling.

    Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Tui Na (Chinese massage), Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment.

    I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable.

    I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Chinese and Japanese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan.

    This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections or collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility.

    I will inform my practitioners immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *

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