Informed Consent for Treatment

DR. Sze Acupuncture & Bone-Setting Clinic

Consent Statement

Health care guidelines in Canada require that all health practitioners have their patients sign a consent form indicating that they agree to be examined and treated by the practitioner. In keeping with these regulations please read the following and sign at the bottom.

I, (the undersigned), declare that I have received information about the nature and course of traditional Chinese medical treatment, Herbal medicine, Acupuncture and Bone setting, benefits, risks, and potential discomfort (including but not limited to temporary soreness, bruising, blistering, nausea, fainting, bleeding, burning, infection and shock). I do not expect the practitioner to be able to anticipate and explain all possible risks and complications. I wish to rely on the practitioner to exercise judgment during course of the procedure which they feel at the time, based upon the facts then known, is in my best interests.

The practitioner has responded to all my requests for further information about the services proposed.

I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above mentioned procedures. I intend this consent to cover the entire course of treatment for my present and for any future conditions for which I seek treatment.

I understand that my consent is required prior to releasing my records to another practitioner, insurance company or any other agency or person except where required by law.

In respect of receiving assessment and treatment by:

Tak Heung Sze, Doctor of Traditional Chinese Medicine, Registered Acupuncturist, in Calgary, Alberta.

General Information

Last Name *

First Name *

Gender *

Male Female

Birth Date *

Phone *

Email *

Address *

City *

Postal Code *

Current or previous occupation(s)

Insurance Information (Optional)

Do you have health insurance?

Yes No

Insurance Company Name

Policy/Certificate Number

Group Number (if applicable)

Policy Holder Name (if different from patient)

Medical History

Chief Complaint / Reason for Visit *

Allergies (medications, foods, or other) *

Current Medications (including herbs and supplements)

Previous Medical Conditions

Previous Treatments for Current Condition

Previous Surgeries

Major Injuries

Previous Hospitalizations

Are you currently pregnant? (for female patients)

Yes No N/A

Emergency Contact

Name *

Phone *

Patient Signature

Please sign in the box below using your mouse or finger *

Date:

By clicking submit, you agree to the terms stated above.