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...)

FULL medical history (with dates)

Relevant family medical history

Current issues

ALL Current medications (including blood thinners, weight loss, contraceptive...)

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.The practitioner reserves the right to refuse or discontinue treatment if it is deemed inappropriate or unsafe for the clientI understand that a treatment session may last between 45 minutes and one hour depending on the treatment, which includes assessment and/or review time.Classical acupuncture practice may involve the use of important points that other practitioners may prefer not to use due to their location; for example, lower abdomen (not genitalia), buttock for sciatica, chest (not breast), armpits, face... Pascal will always check that you are comfortable and agree with the use of these points and protect your privacy at all time with sheets. Alternative distal points can be found and your decision will always be respected. You are encouraged to openly express your views and may change your mind at any point during the treatment.I 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 £35 charge applies or the full amount if your appointment is missed.