VIKTOR NEDELCHEV, R.Ac
434 East Columbia Street, New Westminster,BC
Fuscaldo Chiropractic Total Health Centre
Office: 604-515-7018 Fax: 604-515-7058
Cell: 778-865-2123 www.qiinmotion.com

PATIENT CONSENT FORM

Please read and sign the following document and bring it with you on your first visit.
Please note that all information is strictly confidential!

Acupuncture uses thin sterile needles to adjust the body’s acupuncture channels and regulate organ’s function through energetic manipulation. Acupuncture is generally very safe method of treatment however in some cases mild bruising and slight pain may occur at needle site and also may causes dizziness, fainting and rarely pneumothorax. The use of sterilized disposable needles at this clinic eliminates the risk of Hepatitis B, C and HIV transmission.

I consent to acupuncture treatment and other procedures associated to the Traditional Chinese Medicine. I have discussed the nature of my treatment with my acupuncturist. I was told that the methods of treatment may include but are not limited to Acupuncture, Moxibustion, Cupping, Gua Sha, Tui Na massage, Electro-acupuncture, Ear acupuncture and Laser acupuncture.

I have been advised to consult a physician regarding my condition for which I am seeking acupuncture treatment.

I am seeing Viktor Nedelchev as registered acupuncturist of my own choice with the intention of receiving natural therapy for my health complaints. I understand that the Traditional Chinese Medicine offers just one aspect of my health care.

I have read and understand the above and hereby give consent to Viktor Nedelchev R.Ac to perform a treatment on me. I intend this consent to cover the course of treatment for my present and for any future condition for which I seek treatment.

PATIENT NAME:

SIGNATURE:

DATE: