FOR FEMALES ONLY
Please read the terms and conditions carefully, and do not hesitate to ask the Practitioner for clarifications for anything that you do not understand.
1. Take Note That, all information requested in this form must be completed fully and accurately. Failure to provide all information requested herein may adversely affect the acceptance of any claim(s) you may make in the future.
2. I understand that I will be evaluated by a physician for the condition that I am requesting consultation and that the diagnosis and treatment plan I will be given by Annie Tiang TCM is based upon Traditional Chinese Medicine principles and natural treatment only and does not constitute a western medical diagnosis.
3. I will provide Annie Tiang TCM with my full and detailed body and health conditions, medical history and medication taken.
4. I understand that Physician may during the diagnosis prescribe treatment procedures, such as acupuncture, moxibustion, scraping, cupping, traction, equipment-based therapies and any other treatments necessary for my condition.
5. I understand and am informed that in the performance of these procedures, there are possible risks and complications which may include, but not limited to, bleeding, bruising, pain, faint, convulsions, burn, stuck, pneumothorax, numbness, dizziness, insomnia, blisters, cupping marks or bent needles and any other known risks, and these would be informed by the Physician to the best of his knowledge.
6. I understand that the Therapist may administer such treatment procedures (other than acupuncture] as part of the Physician’s prescription and these will be performed under the supervision of the Physician.
7. I will follow closely to the schedule of treatments as recommended by the physicians and therapists to have the best healing effects of the treatment plan.
8. I understand that this information will be treated with strict privacy and will only be used by the clinic staff involved in rendering the treatment procedure(s).
9. I will follow the physician’s comments and advice during my treatment(s) and I agree to the Terms & Conditions herewith.
10. I declare that all the information I have given in this application is true, correct and complete, and is not false or misleading.
11. I confirm that I have read, understood and completed this questionnaire to the best of my knowledge. I accept full responsibility for the answers given.
What is Acupuncture?
Acupuncture is a form of therapy in which fine needles are inserted into specific points in order to create neuro-physiological reactions in a body and stimulate a healing effect.
Is Acupuncture safe?
Acupuncture is generally very safe. Serious side effects are very rare- less than 1 per 10,000 treatments.
Does Acupuncture have side effects?
You need to be aware that:
Single-use, sterile, disposable needles are used in this clinic.
It is our duty to inform you of any risks associated with our treatment techniques.
Some therapy techniques such as therapeutic massage, joint manipulations, traction, chiropractic, moxibustion and cupping have a very slight risk of causing injury. A remote possibility of injury to structures such as but not limited to: nerves, bones, muscles, ligaments, discs, or arteries exists. Research evidence indicates that skilled cervical (neck) manipulation is safer than taking anti-inflammatory medication and these techniques are among the safest for treatment of musculoskeletal complaints. In very rare circumstances (less than 1 in 2 million), damage may occur to the vertebral arteries in the neck and the patient may suffer a stroke. There is a small risk that treatment may produce pressure on nerves going down the arm or leg.
Electro-physical agents such as ultrasound or interferential therapy have been linked to minor burns and abnormal skin reactions.
Acupuncture and the above listed techniques can occasionally cause temporary local swelling, bruising or transitory increases in the levels or distribution of pain or other symptoms. In very rare cases acupuncture has been reported as being associated with bodily infections or collapse of lung.
Allergic skin reactions to massages oils, strapping tapes, acupuncture needles, or topical applications are a possibility.
A follow-up consultation is required if you still experience discomfort after 3 days.
Following the verbal explanation of my examination results and the therapeutic techniques the therapist and/or Practitioner thinks suit my present condition, I understand the risks and give my consent to treatment. I have the right to decline treatment that the therapist and/or Practitioner offers me at any time. I have the right to a second opinion at any time. Annie Tiang TCM would not be liable should you seek western treatments for follow-up appointments. I give permission to the therapist and/or Practitioner to exchange information with my other Doctors and other medical specialists when necessary.
I understand that this information will be PRIVATE AND CONFIDENTIAL.
I HAVE READ THIS FORM, UNDERSTAND THE INFORMATION IT CONTAINS, AND GIVE MY CONSENT TO TREATMENT.