Patient Intake Form

It is very important that you see a fully-trained Chinese medical practitioner who understands your medical history. Chinese herbs are powerful so the right combination of herbs needs to be prescribed for your unique concerns and based on your constitution.

Side-effects are uncommon but when they do happen they are typically digestive in nature such as changes in bowel movements or transient nausea. Both of these tend to last forty-eight hours as your body adjusts to taking the herbs.

It is important that I understand any medications or supplements you are taking so I can advise you on an appropriate dosing schedule.

As with all my treatments, your safety is of utmost importance to me. As a registered practitioner of the Register of Chinese Herbal Medicine (RHCM), I only prescribe authenticated Chinese herbs that have been quality assured by using only RCHM-approved suppliers. These suppliers must fulfil rigorous criteria following a thorough investigation by independent auditors, which includes demonstrating that the herbs are manufactured according to Good Manufacturing Practice (GMP) standards. These are important safeguards for ensuring safety standards are met and that you receive the best quality herbs available.

Acupuncture is generally extremely safe and is carried out using single-use, sterile disposable needles. You should always turn to a fully qualified and insured practitioner for acupuncture, which I am.

Side effects of treatment are very rate - less than 0.01% of treatments. However, you need to be aware that:
* Drowsiness can occur after treatment and, if affected, you are advised not to drive;
* Minor bleeding, bruising and haematomas occur in around 2% of acupuncture treatments;
* Pain during treatment occurs in about 1% of treatments but I am very sensitive to this and would always remove needles that caused discomfort. I very much work with my patients comfort in mind.
* Existing symptoms can get worse after treatment in less than 3% of patients before improvements are observed. This is usually a positive sign so do tell me if this happens.
* You can sometimes feel a bit faint if you are very weak, hungry or tired. Please ensure you have eaten within 2 hours and are not excessively tired before your session.

• Please minimise your activity immediately after your acupuncture treatment and avoid stress or over-exertion at work, home or the gym;
• Avoid stimulants such as caffeine, smoking and alcohol after treatment for the rest of the day;
• Drink plenty of water after your treatment;
• Please be aware that blood donors are required to wait 6 months from the date of the last acupuncture treatment before giving blood;
• Please inform me if you have any newly diagnosed conditions or newly prescribed medications during your course of treatment.

I operate a forty-eight hour cancellation and rescheduling policy to allow sufficient time to contact another patient who may be on the waiting list.  Please contact me as soon as you are aware that you are unable to keep your appointment.  I reserve the right to charge the full cost of the treatment if you fail to turn up for your appointment or if you cancel with less than forty-eight hours’ notice.

HOW YOUR CONTACT INFORMATION IS USED

Your contact information will be used to stay in touch with you regarding your treatment.  If you wish for Chinese herbal medicine to be delivered to you, your contact details will be used unless you give other instructions.

WHO HAS ACCESS TO YOUR INFORMATION?

All healthcare professionals and staff must comply with the requirements of the Data Protection Act 1998 and the EU’s General Data Protection Regulations.  This covers the collections, storage, processing and disclosure of your personal information.  Your information is strictly private and confidential.

Communication with another healthcare professional outside of the clinic will not happen without your consent or unless required by law.