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Patient Consent To Treatment

The services provided in this clinic include: herbs, acupuncture, moxibustion, cupping and dietary based on Traditional Chinese Medicine.

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The side affects may occur in a small percentage of patients and may include the following: some pain following treatment in the treated area, minor bruising or bleeding, blisters after cupping, or minor infection and needle sickness (fainting). If you have a severe bleeding disorder, a pacemaker, or you are pregnant, please let the treating practitioner know prior to treatment.

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By fill the personal information, select the check box "I accept terms & conditions", complete the "Medical History and Symptoms (Questions form 1 and 2)" below. I agree to receive the treatments according to the diagnosis of the TCM practitioner Rong (Lydia) Li.

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**Please submit all the information above mentioned to complete this agreement (Patient Consent To Treatment)**

Thanks for submitting! Please complete Medical History and Symptoms (Questions form 1)

Medical History and Symptoms (Questions form 1)
Thyroids
Urine
Prostate
Sweat
Allegies
Weight

Thanks for submitting! Please complete Medical History and Symptoms (Questions form 2)

Medical History and Symptoms (Questions form 2)
Gender
Dietary restrictions,if any of bowel movements per day.Please indicate if you regularly experience either
Menstrual Cycle
Blood presure
Body pain
Blood sugar

Thanks for submitting! I will contact you later

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