Medical information Please mark Yes/No Points used Epilepsy Pacemaker Full name Date of birth Phone number Email address Are you happy to be added to my mailing list? Emergency contact details Hemophilia Psoriasis Pregnancy K/S If you mark for any of the above, you will still be able to receive treatment but the ‘Yes’ number of needles will be modified. Notes about treatment 5 needles will be placed into each ear. The needles will be left in for 30-40 minutes. All needles are sterile and are disposed into a sharps bin after use. If you feel light headed let the practitioner know at once (it helps to eat before hand). Needles may fall out during treatment, please let the practitioner know if this happens. Benefits accumulate the more treatments you have. Some practical points Use the toilet and switch off phone before the treatment. Ensure bags and coats are well away from your chair. Do not get up and walk around with the needles in. Tie hair back to avoid needles being knocked out. The Blood Transfusion Service require all recipients of acupuncture to refrain from giving blood for 6 months after treatment. Drink plenty of water after the treatment and avoid drinking alcohol. Benefits: Side Effects: Increases mental clarity and There are no contra-indications to the concentration treatment although some minor side Reduces feelings of anxiety, stress, effects may include: frustration and anger Slight pain on insertion Deeply relaxing Feeling tired after treatment Stimulates the body to heal itself Feeling light headed Helps with cravings & detoxification Slight bleeding from the point used Improves low mood and sleep in the ear I agree to inform the practitioner of any changes to the above medical conditions and give consent to treatment. Print Name Signature
Full name Date of birth Phone number Email address Are you happy to be added to my mailing list? Emergency contact details Medical information Please mark Yes/No Points used Epilepsy Pacemaker Hemophilia Psoriasis Pregnancy K/S If you mark ‘Yes’ for any of the above, you will still be able to receive treatment but the number of needles will be modified. Notes about treatment 5 needles will be placed into each ear. The needles will be left in for 30-40 minutes. All needles are sterile and are disposed into a sharps bin after use. If you feel light headed let the practitioner know at once (it helps to eat before hand). Needles may fall out during treatment, please let the practitioner know if this happens. Benefits accumulate the more treatments you have. Some practical points Use the toilet and switch off phone before the treatment. Ensure bags and coats are well away from your chair. Do not get up and walk around with the needles in. Tie hair back to avoid needles being knocked out. The Blood Transfusion Service require all recipients of acupuncture to refrain from giving blood for 6 months after treatment. Drink plenty of water after the treatment and avoid drinking alcohol. Benefits: Increases mental clarity and concentration Reduces feelings of anxiety, stress, frustration and anger Deeply relaxing Stimulates the body to heal itself Helps with cravings & detoxification Improves low mood and sleep Side Effects: There are no contra-indications to the treatment although some minor side effects may include: Slight pain on insertion Feeling tired after treatment Feeling light headed Slight bleeding from the point used in the ear I agree to inform the practitioner of any changes to the above medical conditions and give consent to treatment. Print Name Signature