Alberta Acupuncture Intake

Name
Preferred Contact By:

CallTextEmail
Address
City Province
Postal Code
Phone (Home)
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Marital Status

SingleMarriedOther
Preferred pronouns
Occupation
Emergency Contact Name
Relationship
Emergency Contact Phone
Referred By
Family Physician Name
Phone
Clinic Name and Address
Main Complaints

Please list your health concerns and complaints in order of importance, how long you have had it and treatments that you are receiving or have received.
1
2
3
4
5
Please mark the complaint area indicating the letters on this chart. (example: A, L, T)
Please select your pain scale (0 = no pain, 10 = the worst pain possible )

012345678910
Please select abnormal sensations

burningspasmnumbnesstinglingwarmcold
Is this condition related to a car accident?

NoYes
If yes, Date of lose

MonthDayYear
Date
Please select the service you would like to receive

MassageAcupunctureOsteopathyCuppingTCM
Have you had this type of service before?

NoYes
Are there areas of your body that you are sensitive to being touched? (e.g. feet, hands, face, etc.)
Medical history
Allergies: Please list any food, drugs, medications or environment factors which you are sensitive or allergic to
Illness: e.g. diabetes, hypertension, migraines, scoliosis, MS, stroke, autoimmune disease, fibromyalgia, including transmissible disease
Operations
Injuries: i.e. Fractures, sports injuries, car accidents, etc.
Presence of man-made medical or engineered components: e.g. prosthetics, pacemakers, implants, pins
Current Medication 1
Dosage
Frequency
How long have you been taking it?
Current Medication 2
Dosage
Frequency
How long have you been taking it?
Current Medication 3
Dosage
Frequency
How long have you been taking it?
Current Medication 4
Dosage
Frequency
How long have you been taking it?
Current Medication 5
Dosage
Frequency
How long have you been taking it?
Accuracy of Information
By initial at the end of this paragraph, I confirm that the above information is accurate and true to my knowledge. I hereby release the providers at Alberta Acupuncture Massage Clinic & Blue Quill Wellness Centre from any and all liability should any problems arise from the treatments I receive due to any incorrect information I have given, or any information requested in this health history that I withheld.
Initial here:
Privacy and Sharing of Information
I authorize the clinics and their associated health providers to collect my personal and medical information as documented above. In addition, I authorize the clinics and their associated health providers to communicate with my family doctor and /or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information are confidential and will only be disclosed to third parties with my permission.
Initial here:
Informed Consent For Treatment

I have informed my therapist of all my known physical conditions, medical conditions and medications and I will keep my therapist updated on any changes to my health history.

I hereby request and consent to the performance of the service I indicated in the form. The therapist will be performed by registered practitioners.

I understand that results are not guaranteed. I further understand that I am informed, as in all health care, in the practice of the type of therapy that I indicated in this form , that there may be side effects (post treatment soreness, redness, post cupping blisters, post acupuncture bruises, mild bleeding,etc.)

I wish to rely on the therapist to exercise judgment during my treatment. By signing below, I agree to the therapy that I indicated in this form.

This consent form will cover the entire course of treatment for my present condition(s) and for any further condition(s) which I seek treatment for. I am aware that I may withdraw this consent and stop treatment at any time.

By signing down below , I give my informed consent to receive treatment at Alberta Acupuncture Massage Clinic / Blue Quill Wellness Centre
Client signature

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Date

MonthDayYear
Date
Appointment Cancellation Policy

We understand that unplanned issues can come up and you may need to cancel or reschedule an appointment. If that happens, we respectfully ask for at least 24 hours notice in advance to avoid any cancellation fees.

Our Service Providers want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses an opportunity to be seen. No-show appointments, and those appointments not canceled or rescheduled within 15 hours prior to the appointment, will be charged Full Price of the service value that was reserved for. However if the appointment is canceled within the 15 to 24 hours mark prior to the appointment, it is considered as late cancellation and is charged 50% of the service value that was reserved for, it is to ensure compensation to the staff for their valuable time.

Thank you for being a valued patient, for your understanding, and your cooperation as we institute this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all our patients.

We do understand emergency and special situations do come up, please do contact us anytime for these reasons to avoid extra charges.

Please print & sign below to consent to these terms.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty: