Welcome to HamsterPuncture!  

Edward P. Layton, LAc.  1609 Broadway Suite 202 Bellingham WA 98225

PLEASE FILL OUT THIS FORM, PRINT IT OUT AND BRING IT WITH YOU TO YOUR FIRST APPOINTMENT

Patient Name: __________________________ Age: ____Birth Date: ___/___/___ Gender: M/F


Address: ___________________________________________________________________

City: _______________________________________________State: _____ Zip: __________

Telephone: (H) ___________________ (W)___________________ (C) _________________

Email:__________________________________________ Occupation:_________________

For your information, I use disposable sterile acupuncture needles which are disposed of following OSHA guidelines for biochemical waste. I am a state licensed acupuncturist.

Consent for Treatment

I, the undersigned, freely consent to treatment by Edward P. Layton, licensed acupuncturist (LAc.).

I understand that treatment will include the use of acupuncture needles. I fully understand that the risks of treatment, although very limited, could include slight bruising from the needles.

If I use and/or have a pacemaker, heart problems, metal plates or rods in my body, an infectious disease, am taking herbs, supplements or pharmaceuticals I will inform the practitioner before treatment.  If I am pregnant, trying to conceive or suspect that I might be pregnant, I agree that I will inform the practitioner before beginning treatment.

If I do not give HamsterPuncture at least 24 hours notice prior to my canceling of a scheduled appointment, I agree to take financial responsibility for the missed/cancelled appointment.  

I accept that Edward P. Layton, LAc. cannot be held liable for any intentional misrepresentations by myself. I state that I have read the “Consent for Treatment” and the Notice Of Privacy Practices forms in their entirety and understand and accept the risks involved in treatment.  

Patient Signature: _________________________________________ Date:________________  

For those patients under 18 years old :

Guardian Signature:_____________________________________________Date:____________________

Primary Reason(s) for Visit:                            Pain/Discomfort Level (3 = Most Painful)

1) ______________________________________                 0        1        2        3

2)______________________________________                   0        1        2        3

3)______________________________________                 0        1        2        3


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