New Patient Intake FormTo make the most out of your first visit, please complete our “New Patient Intake Form” which will help us to understand your main condition. SECTION 1: CONTACT INFORMATION Please provide your contact details so that we can get in touch with you about your treatment. In the event of a medical emergency we will call your emergency contact. Title First Name * Surname * Home Address (Line 1) * Home Address (Line 2) Home Address (City/Town) * Home Address (County) * Home Address (Post Code) * Home Phone Number Mobile Phone Number * Email Address * Emergency Contact In the event of a medical emergency please contact: Name of Emergency Contact * First Name Last Name Relationship Phone Number of Emergency Contact * Name of GP Name of GP Surgery * Phone Number of GP Surgery * SECTION 2: MEDICAL INFORMATION This information will be used as part of your diagnosis, treatment plan and direct care. It will be kept in your medical record. We will not share your medical record with other companies unless you give us permission to. Date Of Birth Sex Martial Status Number of Children 0 1 2 3 4 5 6 7 8 9 10 Occupation What is the main reason for your visit? What other health concerns do you have? What medications are you currently taking? What supplements are you currently taking? What allergies do you have? e.g foods, medicine, materials or chemicals What other treatments are you currently receiving? Which Chinese medicine treatments have you received before? Please tick. Acupuncture Chinese Herbal Medicine Cupping Moxibustion Please tick if the following conditions apply to you either currently or in the past: Diabetes Thyroid condition High cholesterol Digestive condition Skin condition Liver condition Heart condition Stroke High or low blood pressure Haemophilia Deep vein thrombosis/blood clots Phlebitis (inflammation of a vein) Fitted pacemaker Osteoporosis Arthritis Fitted artificial joint Injuries/sprains/fractures Gynaecological condition Possibly pregnant at the moment Hepatitis HIV/AIDS Contagious illness e.g. coronavirus, norovirus, MRSA, head lice, impetigo, herpes, ringworm Lung condition Kidney condition Mental health condition Epilepsy/faints Recent/Upcoming surgery Please provide further details of any conditions that you have ticked above: Please provide details of any other medical conditions you have diagnosed with, or injuries you have sustained, that are not detailed above: Please provide details of any surgical procedures you have received in the last 10 years: Please provide details of medical conditions in your immediate family: i.e. spouse, parents, siblings, children, grandparents, grandchildren : SECTION 3: INFORMATION ABOUT YOUR TREATMENT This section contains important information you need to know about your treatment before you agree to receive treatment with Lily. Please read this carefully and speak to us if there is anything that you have queries about before you consent to treatment. Does acupuncture have side effects? Acupuncture is generally very safe and is carried out using single-use, sterile disposable needles. Lily is fully qualified and insured and is a registered member of the UK’s main Acupuncture and Chinese Herbal Medicine professional bodies. All used needles and contaminated waste products are properly disposed of on a regular basis by a registered Clinical Waste Disposal Unit. Side effects of treatment are very rare - less than 0.01% of treatments. However, please 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 3% of acupuncture treatments; • Pain during treatment occurs in about 1% of treatments. Lily will remove the needle immediately if there is significant discomfort; • Existing symptoms can get worse after treatment in less than 3% of patients before improvements are observed. This is usually a positive sign so please inform Lily if this happens; • Fainting can occasionally occur if you are feeling very weak, hungry or tired. Please ensure you have eaten within 2 hours and are not excessively tired before your session. Does Moxibustion or Fire Cupping have side effects? Moxibustion and Fire Cupping are warming therapies that form part of the Chinese medicine treatment family. Both are extremely safe when carried out by a competent practitioner. Before undergoing these treatments however, patients should be aware that: Moxibustion • Whilst safe to use in pregnancy, extra care needs to be taken so please advise us if you are aware you are currently pregnant, or could be pregnant; • Contra-indicated if you have high fever, acute skin infection, open wounds or high blood pressure; • Particular care will be taken in patients with diabetes or neurological conditions that affect skin sensitivity. Fire Cupping • Cannot be carried out in patients with haemophilia or bleeding disorders; • Cannot be carried out directly over skin lesions including varicose veins, spider veins, inflammatory skin conditions, acute skin lesions or new tattoos (but can be carried out in other parts of the body); • We'll take extra care if you have lymphoedema or anaemia; • We'll also need to take care if you have diabetes with complications or an acute infection; • Please note Fire Cupping may result in marks that look like bruises being left on the body that can take 24 hours to 2 weeks to dissipate. Is there anything else we need to know? Apart from your medical history, it is important that you let us know if you: • have ever experienced a fit, faint or funny turn; • have a pacemaker or any other electrical implants; • have a bleeding disorder; • are pregnant; • are taking any anti-coagulants (blood thinners) or any other medications; • suffer from any viral or bacterial infections; • have damaged heart valves or are at any particular risk of infection. After-care advice • Please minimise your activity immediately after your treatment and avoid stress or over-exertion at work, at home or at 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 us if you have any newly diagnosed conditions or newly prescribed medicines during your course of treatment. Payments We accept payments by credit or debit card, Apple Pay or Google Pay. Chinese herbal medicines are made-to-order and once orders are placed, they unfortunately cannot be returned. Cancellation and Rescheduling Policy Lily operates a 48-hour cancellation and rescheduling policy to allow sufficient time to contact another patient who may be on the waiting list. Please contact Lily as soon as you are aware that you are unable to keep your appointment. We 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 48 hours’ notice. SECTION 4: YOUR PRIVACY & CONSENT TO TREATMENT HOW YOUR CONTACT INFORMATION IS USED Your contact information will be used to stay in touch with you regarding your treatment with us. If you wish for Chinese herbal medicine to be delivered to you, your contact details will be passed to our suppliers to fulfil your order. 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 Regulation. This covers the collection, storage, processing and disclosure of your personal information. Your information is strictly private and confidential. Your confidential information is used and viewed only by healthcare professionals and staff associated with the running of this clinic and only where necessary for your treatment. Communication with another healthcare professional outside of the clinic will not happen without your consent or unless required by law. HOW YOUR INFORMATION IS STORED Lily will keep your medical records for 10 years since your last visit. After this your contact and medical information will be destroyed. Your information is stored on computers that have limited access measures via usernames and passwords or biometrics where possible. When transmitted digitally, your information is encrypted during both storage and transmission using a minimum of 128-bit key encryption. Payment information is not stored unless you specifically opt-in. PROFESSIONAL CODE OF CONDUCT To protect your privacy and to comply with professional codes of conduct, Lily is not permitted to approach patients seen in public. To contact us about your data, remove your consent or to request that your data is destroyed please email us at privacy@acupunctureandherbs.co.uk. Can we send you a feedback form at the end of your course of treatment? * Yes please No thank you Can we sign you up to our newsletter? * This is sent only occasionally and contains updates about the clinic or information concerning Chinese medicine and health. Yes please No thank you How did you hear about Lily? SECTION 5: STATEMENT OF CONSENT In order to proceed with my treatment, I confirm the following: * • I have read and understood the above information and that I can refuse treatment at any time. • I agree to the 48-hour cancellation/rescheduling policy. • I consent to my personal and medical information being used to support my treatment. • I consent to my contact information being used as shown in my preferences above. • I consent to receiving treatment as agreed following consultation. Yes: I provide my consent. No: I have further questions before I can provide consent. No: I do not provide my consent and do not wish to proceed with my treatment. Do you consent to your anonymized medical information being included in clinical audits? * In order to continually improve the level of care provided, Lily carries out regular clinical audits of fully anonymized patient medical information. You do not need to consent to this in order to proceed with your treatment. Yes: I consent to my anonymised medical information being used within clinical audits. No: I do not wish that my anonymised medical information is used within clinical audits.
