Acupuncture and herbal medicine questionnaire and consent form Patient details



Where patient is under 16 years old, details and consent of parent or guardian:

PATIENT MEDICAL HISTORY

Do you (Does the patient, if completing for an under-16) currently suffer from, or have you (they) ever suffered from any of the following?

DETAILS - If you have entered YES above please give any details:

I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture and / or herbal medicine to be carried out by the named practitioner. I confirm that I have been provided with written information on (i) the potential complications associated with the procedure and (ii) appropriate aftercare advice for acupuncture / herbal medicine. I give consent to the practitioner to retain the details provided on this form for a period of 7 years from the last treatment I receive.