Consultation Form
Client's Name
Date of Birth
DD
/
MM
/
YYYY
Email
Phone
How did you hear of The London Acupuncturist?
Friend or family
Google
Instagram
Briefly explain what you need treatment for.
Do you experience pain?
If so, where is your pain located?
Level of Pain
1
2
3
4
5
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7
8
9
Where would you place your level of pain? 1 = slight 9 = debilitating
Are you taking any medication?
please provide name and dosage
Do you currently suffer from, or have you ever suffered from any of the following?
Yes
No
Heart condition/Angina/Blood pressure issues
Epilepsy/seizures
Haemophilia/blood clotting disorders
Skin complaints, e.g. psoriasis, eczema
Diabetes
Allergies
Do you take aspirin or blood thinners?
Do you take prescribed medication?
Could you be pregnant?
If you answered yes to any of the above please give further details.
I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture to be carried out by the named practitioner. Click yes to proceed with treatment.
Consent
You have consented to treatment
Yes
Verification
SEND INTAKE FORM
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