Consent Form - Claire Truss Acupuncture

Name

First

Last

Address

Phone Number (Mobile)

Email

I consent to clinic updates/marketing being sent to my email address by Claire Truss

Yes
No

Referred by

GP Name

GP Address

GP Phone Number

Medical History - select if you currently or have ever suffered from any of the following:

If you have ticked any of the above, please provide further information.

I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture to be carried out by Claire Truss. I confirm that I have been provided with information on the potential complications associated with the procedure, aftercare advice and the privacy notice location, all contained in the “Information Sheet”. (Please print your name below as signature).

Date