Private and confidential patient form

to the exclusive attention of Pascal Da Silva MBAcC ATCM. Your data will never be shared with any third party. This website complies with General Data Protection Regulation.

First name (required) Last name (required) Date of Birth

Clinic you are attending

Date of appointment (required)

Your Email

Phone (required)

Your postcode and house number

Emergency contact, name and phone (required)

Your GP surgery

Occupation

What does your occupation involve (lifting, stress, night shift...)

Age of children

FULL medical history (with dates)

Current issues

ALL Current medications

I confirm to voluntarily seek acupuncture and give informed consent to receive treatments from Mr Da Silva. I understand the risks associated to acupuncture, including but not limited to bruising, minor pain, dizziness or other temporary side effects. I agree to provide accurate and complete medical history, including current health conditions, medications, allergies or other relevant information. I agree to inform the practitioner of any changes in health status and treatment plan.I acknowledge that acupuncture carries inherent risks and that while the practitioner will exercise reasonable care, the practitioner is not liable for any unforeseen adverse effects or injuries that may occur after treatment, except in cases of gross negligence or misconduct by the practitioner.The practitioner reserves the right to refuse or discontinue treatment if it is deemed inappropriate or unsafe for the clientI understand that the privacy policy is available on the website under the Contact tab.I agree to the cancellation policy to allow a 24h notice or a £30 charge applies or the full amount if your appointment is missed.