Acupuncture Consent template

1. Nature of Treatment

• Acupuncture involves the insertion of sterile, single-use needles into specific points on the body to relieve pain and support wellbeing. Treatment may also include cupping, moxibustion, electro-acupuncture, or manual tui na massage, as discussed with your practitioner.

2. Risks and Side Effects

• Acupuncture is generally safe when performed by a qualified practitioner. Possible side effects include minor bruising, bleeding, or soreness at needle sites, temporary light-headedness, and, rarely, infection or fainting. Very rarely, needling can cause organ puncture or nerve injury; your practitioner will discuss any specific risks relevant to your condition.

3. Benefits and Alternatives

• Many clients report relief from pain, stress, and other symptoms, though results vary and no specific outcome is guaranteed. Alternatives include conventional medical treatment, physiotherapy, or no treatment at all; you are free to discuss these options with your GP or practitioner before proceeding.

4. Confidentiality and Data Protection

• Your health records are kept confidential and processed in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018. Information will only be shared with third parties with your consent or where required by law.

5. Cancellation Policy

• Please provide at least 24 hours' notice to cancel or reschedule an appointment. Late cancellations or missed appointments may incur a fee as set out in your practitioner's fee schedule.

Client Information

• Full NameText
• Date of BirthDate
• AddressText
• Phone / EmailText

Practitioner Information

• Practitioner NameText
• Registration / Licence No.Text

Emergency Contact

• Contact NameText
• Relationship / PhoneText

Acknowledgment and Signature

• Client SignatureSignature
• Date signed (client)Date
• Practitioner SignatureSignature
• Date signed (practitioner)Date

• By signing below, I confirm that I have read and understood this consent form, had the opportunity to ask questions, and voluntarily agree to receive acupuncture treatment. I understand I may withdraw consent at any time.