Southcentre Chinese Acupuncture

Family History: please list any serious health conditions your immediate family have/had (diabetes, cancer, heart disease, stroke, mental illness, asthma, etc.)

Addictions

How many do you consume per day

Check the symptoms you have recently (within the last 4 weeks)

For Women

Please add any information that you think may be useful to assess your condition:

If you want to the clinic to direct bill your insurance company, please fill out the direct billing
consent form. Sorry we do direct bill Blue Cross, Co-operator, Industrial Alliance and
Desjardins.

Thank you for completing this form, please feel free to ask any questions you may have. Also please make sure you are not hungry when you come for acupuncture, otherwise, you
might feel a little dizzy after treatment.

Informed Consent for Acupuncture Care

I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary including needling, electroacupuncture and other techniques within the scope of practice of registered acupuncturists.

I have had the opportunity to discuss with the registered acupuncturist the nature and purpose of acupuncture care and other procedures of alternative care. I understand the results are not guaranteed. I further understand that I am informed that, as in all health care, in the practice of acupuncture, even though all needles are presterilized and disposable, there are some slight risks to treatment including but not limited to temporary soreness, bruising, blistering, nausea and fainting. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist to exercise judgement during the course
of the procedures which the acupuncturist feels at the time, based upon facts then known, are in my best interest.

I understand that a 24 hours notice in advance should be given to cancel or change the appointment. Otherwise, I will be charged a full treatment fee. No further treatment would be given unless the penalty has been paid. I acknowledged that a 3% transaction fee will be charged for the refund of package payment, if the reason of discontinuing service is not due to the quality of service. Senior rate is only applied when the visit happens between 9:30 am to 3:30 pm on the weekdays.

I have read the above consent. By signing below, I agree to the above named procedure(s). I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment,