Acupuncture & Remedial Massage Noosa Hinterland
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Client Consent Form

Contact Details

Contact details for each customer and a general survey about customer health related issues.

Step 1 of 3

33%
  • Presenting Conditions

  • e.g. general relaxation, relieve muscle tension in shoulders, legs, etc.
  • DD slash MM slash YYYY
    Please indicate if you have used any of the above within last 12 months.
    Please indicate if you have current or experience within last 12 months.
    This will be discussed at the first and any following appointments.
  • e.g. particular sensitivities, particular areas requiring focus
    Select relevant options and provide details below as necessary.
  • Terms & Conditions

    • I have honestly and comprehensively answered the above questions.
    • I understand that acupuncture treatments involve the insertion of sterile, disposable needles at several points in the body and methods of treatments include the following, depending on the Jacqueline’s judgment:
      • Use of acupuncture to stimulate acupuncture points and meridians
      • Use of an electro-acupuncture device to stimulate acupuncture points and meridians
      • Swedish and/or Tui Na massage
      • Use of moxibustion
      • Acupressure
      • Cupping
      • Gua Sha
      • Dietary advice
      • Auricular ear acupuncture
      • Herbal medicine
    • I understand that the administration of acupuncture could directly or indirectly result in adverse effects to my body including, but not restricted to: light-headedness, minor bleeding, bruising, soreness, pain and general relaxation. I understand that although precautions are made to avoid any medical complications, I will be responsible to seek further medical attention.
    • My health details will be discussed with Jacqueline before treatment begins.
    • Jacqueline will determine a therapeutic strategy appropriate to my needs and within the therapist's scope of practice;
    • Jacqueline will discuss with me instructions about acupuncture and massage procedures, areas of the body to be treated, draping and undressing procedures and positioning options during the treatment;
    • Prior to treatment being confirmed, a physical examination may be required which could include partial undressing and the therapist palpating (touching) me;
    • I can propose alterations to the treatment plan at any stage during the treatment;
    • I can end the treatment at any time and accept there may be financial consequences
    • If I have any questions or concerns, I will seek further information and discuss my concerns with Jacqueline.
    • I have stated all my medical conditions and will keep Jacqueline updated on my health.
    • It is my responsibility to notify Jacqueline if any information provided in this document changes.
    • If at anytime during the session I feel uncomfortable and/or wish Jacqueline to adjust pressure, draping, or room temperature etc, I will tell her so.
    I wish to proceed freely and voluntarily with such treatment and I give my permission for Jacqueline to proceed.
  • Remedial Massage
  • Relaxation Massage
  • Meridian-, Tuina Massage, Shiatsu & Acupressure
  • Foot Reflexology
  • Acupuncture
  • Further Methodes: Herbal Medicine and Dietary Advice
  • Ear Acupuncture
  • Moxibustion / Moxa
  • Electro-Acupuncture
  • Scalp Acupuncture
  • Cupping
  • Gua sha
  • List of indications
  • Chinese medicine information
Acupuncture & Remedial Massage Noosa Hinterland > Client Consent Form

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