Patient Follow Up Form
Required
Current Conditions:
Medication & Medical Appointments:
Required
Required
Current Lifestyle:
Statement of Consent: I declare that the information I have provided on my medical history above is correct to the best of my knowledge and hereby give consent for either/and/or:
- Acupuncture/acupressure/electro-acupuncture
- Tui na (Chinese medical massage)
- Chinese Cupping massage
- Swedish/deep tissue massage
- Reflexology
To be carried out by Miss Lorna Jackson of Health Point Clinic. I give consent to Health Point Clinic to retain the details provided on this form for a period of 7 years from today. I further understand that if I am under 18 years of age, these records will be kept until I reach the age of 25 (7 years after reaching 18).
Cancellation Policy: Please give Health Point Clinic sufficient notice if you wish to cancel or rearrange your appointment. Appointments cancelled within 24 hours may be charged at full fee. Health Point Clinic attempts to keep costs as low as possible and as such a strict policy must be maintained.