Treatment Information and Consent Form

Please read this document carefully, and ask your practitioner if there is anything that you do not understand.

What is acupuncture?

Acupuncture is a form of therapy –used in Chinese Medicine – in which fine, sterile needles are inserted into specific points on the body. The insertion itself is painless, however manipulation of the needles may result in (Deqi) slight sensations such as warmness, heaviness, electric current or mild ache.

What other techniques may be used during the treatment?

During Moxibustion, your practitioner may also use a smouldering herb called ‘moxa ’, which involves safe burning of the herb on- or in proximity to your body.
Tuina Massage is a traditional, medical bodywork, which uses a wide range of techniques. Cupping therapy involves small glass cups, in which suction is created by the use of fire, then placed onto your skin. Guasha techniques are used with a small, smooth-edged instrument, which involves gentle scraping of your skin.
Auricular or electroacupuncture may be used during the treatment. Likewise, they generally have no additional side effects.
We may also use bloodletting techniques in which we would generally use a diabetic lancet -or hypodermic needles- to pierce the skin. Similar to a blood sugar test, we usually only draw a couple of drops of blood. This therapy – done in a sterile environment – is highly effective for pain conditions.

Is acupuncture safe?

Acupuncture is generally very safe. Serious side effects are very rare – less than one per 10,000 treatments.

Does acupuncture have side effects?

You need to be aware of the following possible adverse effects:

  • Minor bleeding or bruising after treatment (3%)
  • Mild aggravation of existing symptoms (3%). This is usually a good sign and quickly improves (in 70% of cases).
  • Drowsiness (1%). If affected, you are advised not to drive.
  • Mild pain at the needle site (1%)
  • Local burning after using ‘moxa’ on the site. Extremely rare; however, it may result in mild blisters.
  • Dizziness (0.6%)
  • Nausea, feeling faint (0.3%)
  • Headache (0.1%)
  • Allergy or infection (<0.2%)
  • Pneumothorax (0.0002, less than 2 per million)

After Cupping, Guasha and Bloodletting treatment:

  • There may be some visible bruising at the site of the treated area. These usually fade within 2-3 days; however, in some instances (when using strong Cupping) they may last up to 2 weeks.
    If you are not feeling comfortable with this treatment, please let your practitioner know.

If you experience any adverse effects –listed above- or notice anything unusual in regards to your health following the treatment, please contact you therapist or GP as soon as possible.

Is there anything your practitioner needs to know?

Although you are not obliged to share any information you do not wish to,
it would be important that you let your practitioner know:

  • If you suffer from fits, epileptic seizures, or tend to faint.
  • If you have a pacemaker, or any other electrical implants.
  • If you have a circulatory disorder including: Deep Vein Thrombosis, embolism, or a bleeding disorder.
  • If you are taking anticoagulants.
  • If you have any allergies (specifically to metals, oils, herbs).
  • If you are pregnant or trying to conceive.
  • If you have a fear/phobia of needles.
  • If you have any particular risk of infection.
  • If you have not eaten within 3 hours prior to your appointment.

Please inform your practitioner if any of the above applies to you, prior to your treatment taking place.

Please note:

  • During your treatment, you may be examined or treated in intimate areas
    (e.g. REN17 – Acupoint in the middle of the chest). We are aware that sensitive/intimate areas vary with different cultures and religions. Therefore, you always have the opportunity to bring a chaperone for the therapy sessions. You will always be treated with dignity, and you will always be asked what you are comfortable with.
  • We pride ourselves on upholding the highest standards of care in our practice. This is also applied to our safety procedures. Therefore, only single-use, sterile, disposable needles are used in our treatments.
  • You have the right to withdraw consent at any time to any part of the therapy, or to withdraw from the therapy altogether.

Terms and Conditions

Cancellation policy

In the event that you must cancel an appointment, please give us as much notice as possible. We will try to reschedule your appointment to the same week so that you don’t miss a treatment. Please note that we operate a 48-hour cancellation policy; therefore, if you do not show up or cancel your appointment between 48 hours and 24 hours prior to your appointment, you will be charged 50% of the full rate. In case you cancel later than 24 hours before your appointment, you will be charged the full fee for your booked session.

Lateness Policy

If you are aware that you are going to be late, please give us a call or send a text message, and we will wait till your arrival. If you arrive 30 minutes after the start of your appointment, your session may be cancelled, and you are responsible for paying the full amount of the fee. Please note that if you arrive late, your session will not be extended beyond your allocated time.

Declaration

I confirm that I have read and understood the information provided in
this form. Thus I will abide by the Terms and Conditions stated above.

I understand what the treatment is likely to involve, the possible side effects and that I have had – and will always have – the opportunity to ask questions regarding my treatments.


I understand that I have the right to withdraw my consent from the treatment at any time.


I confirm I have notified the practitioner about any medical conditions which may affect the treatment, and that I know of no reason for which I should not undergo an (acupuncture/massage) treatment.

I also consent to the examination and proposed acupuncture treatment.