Form TCM | Massage &Acupuncture

Patient Intake & Consent Form

Address:1278 Shillington Ave., Ottawa, ON, K1Z 8A4

Tel: 613-710-9555

Section 1: Patient Information

First name

Last name

Birthday

Year

Month

Day

Gender

Phone number

Address

Section 2: Past Medical History & Ongoing Health Conditions

Family/Emergency Contact (First/Last Name, Relationship, Phone/Email).

Past Medical History (List any relevant past medical history including any hospitalizations, surgeries, prior injuries, or any past medical conditions etc. Include relevant previous family medical conditions or diseases ). Leave it blank if none.

Ongoing Health Conditions (Please list any ongoing health conditions, allergies, drug reactions, and long-term treatments that may be relevant. If you are currently taking any prescription medications, please include them.) Leave it blank if none.

Select applicable condition: Diabetes, Stroke, Heart attack, High/Low blood pressure, Implanted devices, Cancer, Blood clots, Contagious disease, HIV/AIDS, Seizure, Mental illness, Pregnancy, Menstruation, or Other (specify). Leave it blank if none.

Any additional information. Leave it blank if none.

Section 3: Consent to Treatment: Click Here to read the consent. Question Contact (613-710-9555/ clinic1278@gmail.com)

I have read the full consent from the link above. I (or the substitute decision-maker listed below) consent to have my practitioner to perform the following treatment on me: Acupuncture, Cupping, Scraping, Moxibustion, Chinese Herb, Acupressure/Tuina Massage, Chinese Medicine Dietary and Exercise.

I understand and consent that the therapist will need to touch and do treatment on lower back and/or buttocks area if I I have problem at lower back area.

Section 4: Consent to Collect, Use and Disclose Personal Health Information: Click Here to read the consent. Question Contact (613-710-9555/ clinic1278@gmail.com)

I have read the full consent from the link above. I (or the substitute decision-maker listed below) consent for the practitioner to collect, use and disclose my personal health information for the purpose of providing treatment needed.

If you have insurance coverage and need direct billing, please leave the name, contract number and certificate number of your insurance. Leave it black if none.

Signature

Signature field is empty.

ZEN CLINIC

Acupuncture/Massage/eBook/Product

1278 Shillington Ave., Ottawa, ON, K1Z 8A4
Tel: 613-710-9555
Email: clinic1278@gmail.com

Patient Intake & Consent Form