Practitioner: Jin Qi Zeng, Registration# 1779 Tel: 613-710-9555 Primary registered address: 1278 Shillington Ave., Ottawa, ON, K1Z 8A4
Section 1: Patient Information
Section 2: Past Medical History & Ongoing Health Conditions
Section 3: Consent to Treatments
Please read carefully for the following consents.
Contact for questions. Tel: 613-710-9555, clinic1278@gmail.com
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 acknowledge that my practitioner cannot guarantee the results of the proposed treatment.*
I acknowledge that I have been informed about potential reactions that may occur during or after treatment, including but not limited to: (1) Acupuncture: Temporary soreness, bruising, light bleeding at the needle insertion points; (2) Cupping Therapy: Temporary bruising, redness, skin irritation, or in rare cases, blisters at the cupping site; (3) Moxibustion (Moxa): Mild heat sensation, redness, or in rare cases, slight burns or skin irritation;*
(4) Massage Therapy: Temporary soreness, redness, or mild bruising in treated areas. I understand that these reactions are generally mild and temporary, and I agree to inform the practitioner if I have any concerns during or after the treatment; (5) Scraping Therapy (Gua Sha): Redness, temporary bruising, and tenderness in the treated areas; (6) Bloodletting Therapy: Light bleeding, bruising, and temporary soreness at the treated area.*
I acknowledge that I have informed the practitioner about my relevant health history, including whether I have any allergies, metal implants, if I suffer from any type of major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases.*
I understand that I have the right to withdraw my consent to the treatment at any time. I understand that the fees charged for my treatment are not covered under OHIP. I am responsible for the full and prompt payment after services received. I acknowledge that I know the applicable fees.*
I understand and consent that the therapist may need to touch and do treatment on buttocks for problem at lower back area. I understand that other sensitive area includes upper and inner thigh, penis, vagina, breasts, chest wall muscle and need my consent to do treatment on those areas.*
I understand that the practitioner will explain the following to me when I am in the clinic before the treatment, and I can ask any questions I may have: (1) the specific treatment or specific plan of treatment including sensitive areas if needed; (2) the nature of the treatment set out above;*
(3) the expected benefits of the treatment; (4) the material risks of the treatment; (5) the material side effects of the treatment; (6) alternatives to have the treatment; (7) the likely consequences of not having the treatment.*
Section 4: Consent to Collect Use, and Disclose Personal Health Information
I understand that the personal health information that may be collected, used or disclosed by the Clinic may include the following, among other things: • my birth date and contact information • my health history and family health history • my health status • the health care I receive (including identifying my health care provider(s)) • my health number • the identification of my substitute decision-maker, if any • insurance or billing information relating to health care.*
I acknowledge that my personal health information may be collected, used, or disclosed for the following purposes: to deliver the treatment I need, secure payment for services rendered, assist in insurance claim verification, obtain professional advice regarding treatment options, arrange or provide emergency care, and satisfy legal obligations. I understand that in certain instances, my information may be used or disclosed without my consent if allowed by law.*
I understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions.*
I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting the practitioner, but it may directly affect the services I can receive. My personal health information may still be collected, used or disclosed if permitted by law.*