Beijing Acupuncture & Healing Center

Clinic Patient Information and Consent Form

Patient Name:____________________________ Birth Date:___/____/____/ Sex:________

Address:________________________________ City__________________ State______ Zip:________

Telephone: (H)___________________________ (W)__________________ Occupation:____________

Welcome to 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.

Consent For Treatment

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.

I am 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.)

I understand that slight bruising form cupping or needle is normal side effect.

If I 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.

I understand 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.

I state that I have completed the patient information form completely and accurately, and understand and accept the risks involved in treatment.

I further 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

I agree Beijing Acupuncture & Healing Center to leave message in my home or office phone to remain my appointment.

___________________________________________ _______/_______/__________

Patient or Guardian Signature Date: (Month)(Day) ( Year)


Who referred you to us?_____________________________________________________

Who is your primary health care provider/ M.D.____________________________________

Phone: _________________

In an emergency, notify:_____________________________________________________

Phone: _________________ Relationship to you:____________________________

Main problem you would like us to help you with?___________________________________


How long ago did this problem begin:____________________________________________

Have you been given a diagnosis for this problem? If so, what?_________________________

What kinds of treatments have you tried?_________________________________________

Have they helped alleviate the condition/problem?___________________________________

Are you currently receiving treatment for your problem? _______________ If so, please



Past Medical History

Major Illnesses:___________________________________________________________



significant Trauma (i.e.: Motor vehicle accidents, Falls, etc.)___________________________


Medicines: Include prescription, over the counter drugs, vitamins, herbs, etc. taken within the

last one months._____________________________________________________________ _______________________________________________________________________


Stress level:_____________________________

Have you traveled abroad in the past year? _________ Where?________________________