Consent and Initial Intake – Beauty

This form begins to provide us with in-depth background information on your general health and well-being.

The questions are mostly multiple choice, and will take around 10-15 minutes to finish. All information provided in this form is confidential, so please answer truthfully to enable the practitioner to have a deeper understanding of your health and ongoing health care concerns.

Contact phone number

Your Birthdate

Emergency Contact / Next of Kin

Contact phone number

Zhong Centre - Conditions & Informed Consent

As a client, we need you to be aware of and understand the Cancellation policy we have in place at Zhong Centre. Please be aware that if you No Show or Cancel within 24 hours of your booked appointment, the Full Fee (100%) of your booked service will apply. Re-scheduling outside this time frame is fine by contacting us on 0481 825 525.

It is a clinic policy for us to securely and confidentially store credit card details for the purpose of confirming your initial booking. We need you to be aware of and understand that in all forms of health care there may be some very slight risks as a result of Acupuncture and Chinese Medicine treatment. Not uncommon: feeling at the needle insertion site itchiness, minor bleeding, and dull achy feeling possibly lasting up to 2-3 days. Occasionally – temporary exacerbation and/or aggravation of symptoms. Rare – Pneumothorax, nerve pain, punctured organs, hematoma, bruising and needle shock.

I am assured that any questions I may have about my personal care will be fully and honestly answered to the best of practitioner's ability and I am aware and agree with this policy.

Please type your name in the box below to give your consent and you are aware and agree with this policy.

GENERAL HEALTH QUESTIONS
What is the main skin concern that you would like help with?

How long ago did this problem start?

Have you been given a diagnosis for this?

What type of treatments have you tried?

How many cigarettes do you smoke a day?

How many coffee/tea/drinks do you drink a day?

Are you taking any recreational drugs?

Do you have any known drug allergies or reactions?

Are you currently taking any medications or supplements?

Medical Conditions: Check All That Apply
German MeaslesMigrainesProlonged DizzinessChronic FatigueMRGlandular FeverPneumoniaThyroid Problems (Western medicine clinically diagnosed)TuberculosisAsthmaBronchitisOther Lung ConditionsGlasses / Contact lensesHeart AttackHeart MurmurRheumatic FeverOther Heart ConditionsHigh Blood PressureLow Blood PressureGastric / Duodenal UlcerHepatitisIntestinal BleedingBleeding TendencyHaemaphiliaBlood ClotsProblems with AnesthesiaDiabetes Type IDiabetes Type IIKidney InfectionsKidney StonesFrequent UTI's / Bladder InfectionsOther Kidney DisordersRheumatoid ArthritisOestoarthritisOther forms of ArthritisLupus ErthematosusParalysisNeurological DisordersThromboidosisVaricose VeinsBreast CancerUterine / Ovarian CancerProstate CancerBowel CancerLiver CancerSkin Cancer / MelanomasOther CancerLymphnodes removedBreast CystsBreast Lumps (benign)Any ImplantsBotoxCosmetic fillersCosmetic enhancement (tummy tuck, facelift, agumentation, eye lid etc)

Is there any other medical or health conditions that the practitioner needs to be aware of including blood borne diseases?

Do you have any dietary preferences: Check All That Apply
VegetarianVeganPescatarianGluten-freeDairy-freeFructose-freeOther

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