身份证号码 NRIC  

针灸/推拿/拔罐治疗同意书
Consent for Acupuncture / Tuina / Cupping Treatment

患者之声明 Patient’s Declaration:

1. 本人要求及同意接受诊所内注册医师所施予针灸、拔罐、电针、温灯照射，推拿等相关中医治疗。
I hereby request and consent to the administration of acupuncture and other related procedures, such as moxibustion, cupping, electro-acupuncture, tuina and/or use of heat lamp etc.

2. 本人经医师解释并了解针灸，推拿及相关治疗时有可能发生的预后情况，如出血、淤血、疼痛、眩晕、惊厥、烫伤、滞针、弯针等。
I understand and am informed that in the administration of acupuncture and/or other related procedures, there are some risks and side effects involved which include, but not limited to: bleeding, bruising, pain, blisters, burns, dizziness/fainting, palpitations, sweating, convulsions, stuck or bent needles and any other risks as informed by the Physician.

3. 本人了解不应期望医师能预知并解释所有风险及预后情况。本人希望依赖医师的经验及判断得到适当的治疗。
I do not expect the Physician to be able to anticipate and explain all possible risks and complications. I wish to rely on the Physician to exercise his/her judgement during treatment to his/her best ability.

4. 本人患有/曾患有以下疾病，或以下情况
I have or ever had any of the following:

1. 心脏病 Heart disease
2. 心脑血管疾病 Cardiovascular disease
3. 心脏起搏器 Cardiac Pacemaker
4. 糖尿病 Diabetes
5. 高血压 High Blood Pressure
6. 高脂血症 High Cholesterol
7. 贫血 Anaemia
8. 低血压 Low Blood Pressure
9. 正在服用抗凝血药物 Taking anti-coagulants
10. 异常出血 Abnormal Bleeding
11. 癌症 (请注明) Cancer (please specify)
      
12. 肝肾功能不全 Hepatic and renal dysfunction
13. 肝炎 / 乙肝携带者 Hepatitis B
14. 皮肤病 Skin Conditions
15. 皮肤敏感 Sensitive skin
16. 艾滋病 AIDS
17. 性疾病 HIV
18. 其他传染性疾病 Other infectious diseases
19. 惊风 Seizures
20. 癫痫 Epilepsy
21. 晕针病史 History of dizziness / fainting during acupuncture treatment
22. 怀孕 （女性患者） Pregnant (For female patients)
23. 其他 (请注明) Others (please specify):
      


本人了解上述声明，并知道医师并不能保证治疗效果，同时也明白如有需要可向医师咨询更多详情，本人谨此同意并授权进行此项治疗
I have read and understand all the above information and am fully aware that the results of treatment are not guaranteed. I understand that I may ask my Physician for a more detailed explanation if needed. I hereby give my permission and consent to the treatment.

当患者年龄低于18岁或因身体状况无法签署以上同意书，可由家长、配偶、亲属或被授权者代表患者签署同意书。
This consent form may be signed by patient’s representative (e.g., parents, spouse, relatives, or guardian) if the patient is a minor (18 years or below) or physically or legally incapable.