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New Patient Form

Consent to Treatment 
I HEREBY give my consent for acupuncture/massage treatment bearing in mind that a full verbal explanation has been given at the time of treatment.
I UNDERSTAND that if I choose to participate in community acupuncture, this will be done in the reception area with no privacy.
I AGREE to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
I UNDERSTAND that I have to pay for private treatments, cancellation fees and the costs of materials (splints, strappings etc .) and herbs, and any trea tments declined by ACC/work insurance.
I UNDERSTAND that herbs are not refundable.
I UNDERSTAND that any unpaid bills may be referred to a debt collector and I agree that I will be responsible for the debt collection fees, and also the administration fee of $50 incurred for accounts sent to debt collection.
I UNDERSTAND that I have the right to decline part or all of the treatment offered to me at any time and I can ask for a seco nd opinion or change my treatment provider in accordance with Section 7 of th e Code of Health & Disability Services Consumer Rights 1996.
I UNDERSTAND that I can ask the staff for an explanation of treatment I am receiving at any time and that in accordance with Section 10 of the Code of Health and Disability Services Consumer Rights 1996, I have the right of complaint.
I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a fee of the full price of private treatment should I not give sufficient notice.
It is our policy to collect private payment for ACC treatments until the ACC claim is showing on the ACC website as being approved. We will refund the difference once the claim is approved.


Date: April 23, 2024

I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a fee of the full price of private treatment should I not give sufficient notice.

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation:

Gender: *
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?
Have you received treatment of any kind for this condition previously?*
No
Yes

If yes, what sort and was there anything you were not happy about with that treatment?

What aspects were you most happy with?

What are the TWO main things you would like to achieve by the end of today's session?


1.

2.

Why is it important to you that you get rid of your injury/problem as soon as possible?
What is your preferred payment method?*

For your safety and protection and for our information, please answer the following questions:

1. Do you wear a hearing aid or pacemaker?*
No
Yes
2. Do you have any chronic or serious health problems?
diabetes
high or low blood pressure
circulatory/heart problems
fibromyalgia
Arthritis
respiratory disorders
epilepsy or seizures
skin disorders
osteoporosis
blood clotting disorders
Cancer
spinal deviations or disorders
Bursitis
allergies
immune disorders
any communicable diseases
varicose veins
Other

3. Are you pregnant or is there a chance you may be? If so, how many weeks?

4. Are you currently taking any medications? Please list:

5. Do you have any artificial implants (e.g. joint replacement, metal screws etc?)

6. Have you had any significant or recent surgeries/injuries/bone trauma or fractures?

7. Please explain your current symptoms:

Name of GP:

Clinic of GP:
We may contact your doctor to provide them with updates about your progress:*
No
Yes
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of accessto and correction of your personal information held by this practice. No information will be given to a third party without your permission.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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