Acupuncture Health Form

Acupuncture is a treatment technique in which fine sterile needles are inserted into specific parts of the body to produce a therapeutic effect, such as pain relief or improved muscle function.

First Name

Last Name

Date of birth

Email *

Phone *

You Need To Be Aware That:

. Single-Use, Disposable Needles Are Always Used By Lincs Injury Clinic

. All Therapists at Lincs Injury Clinic, providing this treatment have undertaken Recognised External Training to become proficient in delivering this form of treatment.

. This Premises and All Therapists delivering this treatment are Licensed by the Local Council

In A Small Number Of Cases

. Drowsiness may occur and if affected you are advised not to drive.

. Minor bleeding or bruising can occur post-treatment.

. Pain during treatment can occur.

. Existing symptoms can get worse after treatment.

. Fainting can occur in certain clients, particularly at the first treatment.

In addition, if there are particular risks that apply in your case, your therapist will discuss them with you.

Is There Anything Your Therapist Needs To Know?

Is The Person Being Treated 18+ Years Old (We Can Only Treat You If You Are 18+ For Acupuncture)

Yes

Are You Pregnant Or Trying To Become Pregnant

Yes

Have You Ever Experienced Seizures, Fainting Or Had A Funny Turn?

Yes

Do You Have A Pacemaker or Any Other Electrical Implants?

Yes

Do You Have A Metal Allergy Or Needle Phobia?

Yes

Are You Diabetic, Immuno-Deficient Or Have A History Of Cancer

Yes

Are You Taking Anti-Coagulants (Blood Thinners) Or Any Other Medication Or

Yes

Do You Have Damaged Heart Valves Or An Unstable Heart Condition?

Yes

Do You Have Any Blood Disorders? (Haemophilia, HIV, AIDS, Hepatitis C)

Yes

If You Answered 'Yes' To Any Of The Above Please Explain Further In The Space Provided Below

Statement Of Consent

I have read the above form and completed the questions to the best of my knowledge. I have also had the opportunity to ask questions about its content, and by signing and submitting this form I agree I am Over 18+ and agree to the above mentioned Acupuncture Procedure.

I intend this consent form to cover the entire course of treatment for my present and future conditions for which I seek treatment.

I am aware that I can refuse treatment at any time.

Typed Signature