Beijing Acupuncture & Healing Center
ClinicPatient Information and Consent Form
PatientName:____________________________ Birth Date:___/____/____/ Sex:________
Address:________________________________ City__________________ State______ Zip:________
Telephone: (H)___________________________ (W)__________________ Occupation:____________
Welcometo Beijing Acupuncture & Healing Center! We are glad you have chosen us to help server your healthcare needs. For your information, we use acupuncture needles that are for one time use only, and we disposed of following OSHA guidelines for biomedical waste. We remind you that there is always at least one licensed over 25 years experienced Oriental Medicine Practitioners.
I, the undersigned, understand that the Beijing Acupuncture & Healing Center is facility for professional practitioner. I understand that treatment may include the use of disposal acupuncture needles, cupping, mineral heat lamp, acupuncture pressure, emotional advice, Chinese Massage (Tui Na), electrical stimulation and diet counseling, auricular acupuncture.
Iam fully understand that the means and risks of Traditional Chinese Medicine (TCM) treatment, although limited, could include the following: Mini-Burns from a mineral heat lamp, bruising, the fainting induced by needle stimulation, premature labor in pregnant females (Some acupuncture points should not be used with pregnant females.)
Iunderstand that slight bruising form cupping or needle is normal side effect.
IfI use a pacemaker, have heart problems, have metal plates or rods in my body have an infectious disease, am taking herbs or any drugs, am pregnant or suspect that I am pregnant, I agree that I will inform the practitioner before beginning the treatment.
Iunderstand that TCM may affect people, on all levels: physical, emotional,, mental and spiritual, because it works within the entire body to restore balance, I understand that the duration of treatment varies person to person depending on the specific illness and body constitute.
I fully understand that there is stated or implied guarantee of success or effectiveness after a specific treatment or series of treatments . I agree that Beijing Acupuncture & Healing Center can not be held liable for any intentional misrepresentation by myself.
Istate that I have completed the patient information form completely and accurately, and understand and accept the risks involved in treatment.
Ifurther understand that it is Beijing Acupuncture & Healing Center policy to charge a $ 25 fee for check that are returned for non-sufficient funds, and that a 24 hour notice for cancellation of appointment is required. Beijing Acupuncture & healing Center reserves that right to charge full price for any missed appointment without prior 24 hours notification
Iagree Beijing Acupuncture & Healing Center to leave message in my home or office phone to remain my appointment.
Patientor Guardian Signature Date: (Month)(Day) ( Year)
Whoreferred you to us?_____________________________________________________
Whois your primary health care provider/ M.D.____________________________________
Inan emergency, notify:_____________________________________________________
Phone: _________________ Relationship to you:____________________________
Mainproblem you would like us to help you with?___________________________________
Howlong ago did this problem begin:____________________________________________
Haveyou been given a diagnosis for this problem? If so, what?_________________________
Whatkinds of treatments have you tried?_________________________________________
Havethey helped alleviate the condition/problem?___________________________________
Areyou currently receiving treatment for your problem? _______________ If so, please
significantTrauma (i.e.: Motor vehicle accidents, Falls, etc.)___________________________
Medicines: Include prescription, over the counter drugs, vitamins, herbs, etc. taken within the
lastone months._____________________________________________________________ _______________________________________________________________________
Haveyou traveled abroad in the past year? _________ Where?________________________