The purpose of this form is to ensure that you, the Patient:

• Recognise your right to information about what is being offered. 
• Recognise your right to understand the treatment you receive and to choose at all stages whether or not to receive the treatment. 
• Recognise your right to know the standards of confidentiality maintained by those providing your care. 
• Recognise your right to make informed decisions in respect of what information you disclose during the treatments and that you know for what purposes the information may be used. 

By signing this form, you are agreeing to and confirming that you understand and accept all of the following;

Voluntary Consent - Patient Responsibility

• Any information you provide the NRQi Studio practitioner will be held in the strictest of professional confidence and used by your practitioner for diagnostic learning purposes.
• With your consent, we may share your information with your GP, if deemed appropriate.  However if your NRQi Studio practitioner believes that your welfare is at risk or if a safeguarding issue has arisen, we are obliged to contact your GP, even if you do not give consent.
• You understand that you may withdraw your consent for any procedure, treatment or the use of any of your personal information at any time without the need to explain your decision.
• You understand that in this situation where you withdraw your consent, NRQi Studio will be unable to offer you any further appointments.
• If you do wish to withdraw your consent, then please contact NRQi Studio directly via the website. 
• You understand that it is your responsibility as a patient to inform NRQi Studio practitioner about all aspects of my health and that as treatment progresses, to inform my practitioner of any changes that occur.
• You understand that some NRQi Studio treatments are not recommended within 12 weeks of having cosmetic surgery, Botox injections and/or dermal fillers.  You agree to disclose to your practitioner if you have recently had any of these procedures so that an appropriate treatment can be created with your health and safety being the utmost priority. 
• You understand that to maximise the benefits of an NRQi Studio treatment, it is advisable that afterwards you avoid strenuous exercise and alcohol. It is also best to avoid driving any long distance immediately after treatment. It is highly recommended that you drink 2-3 glasses of water or caffeine-free tea over the following 6 hours after the appointment. 

NRQi Studio Treatments - Patient Rights

• You authorise that an NRQi Studio practitioner  can administer NRQi Studio treatments, as deemed necessary and/or appropriate to you, your child (under 18 years of age), a child that is in your care or a patient for whom you are legally responsible and the NRQi Practitioner will have overall responsibility for your treatment.
• You are welcome to ask for any information to allow you to understand any treatment you are offered and your NRQi Studio practitioner will inform you beforehand if they are suggesting that a treatment which is new to you is to be used.
• You understand that you will be treated in a clinic setting where patient privacy is the utmost priority. 
• You understand that the clinical and administrative staff may review your patient records, but all your records will be kept confidential and will not be released without your written consent.
• You understand that your NRQi Studio practitioner will give you explanations as to any specific areas of your body that may need to be exposed for treatment, without coercion or pressure, you will be offered sufficient time to decline treatment should you wish.
• You need to confirm that, to the best of your knowledge, you do not have Trypanophobia (an extreme fear of needles), as acupuncture involves the insertion of needles. 
• You understand that NRQi Studio treatments involve manual palpation and the use of sterile, single-use acupuncture needles.
• You understand that one or more of the following treatments may be included in your treatment.
• Acupressure - finger pressure applied to specific points on the body
• Auricular Acupuncture- the application of insertion of sterile acupuncture needles to the ear
• Cupping - the application of glass cups to the skin
• Dietary advice - nutritional information based upon the principles of Chinese Medicine
• Gua Sha - the application of scraping the skin to expose a sha
  
• Moxibustion - the application of heat to the skin
• Tui Na - bodywork / massage that follows the principles of Chinese Medicine
• You understand that your NRQi Studio practitioner often incorporates the use of Moxa into their treatments. Further information about Moxibustion can be found on our website. 
• You confirm that you have read through the website information and to the best of your knowledge do not have an allergy to Moxa (Folium Artemisiae Aagyi) nor an allergy to smoke inhalation.
• You understand that if you do not wish to have Moxa as part of your treatment, you will be able to inform your NRQi Studio practitioner.
• Transcutaneous Electrical Nerve Stimulation (TENS Machines) are used for pain relief and are usually attached to acupuncture needles using two or more electrodes.  You understand that you may ask your NRQi Studio practitioner to explain the use of this machine if it is to be employed during your treatment.
• You understand that there are can be possible side effects related to the your (the patient's) healing response and have been informed that the treatments employed by Nickila Robertsson, founder of the NRQi Studio, are generally safe, but there may be some side effects  which are described below.
• Acupressure - tingling, slight discomfort, aching pain and possible bruising
• Auricular acupuncture- bruising, numbness or tingling near the needle sites that may last a few days and the possibility of dizziness or fainting.
• Unusual risks of acupuncture can include: spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax).
• Infection is another possible risk, although sterile disposable needles are used with all patients to maintain the safest and most sterile treatment environment possible.
• Cupping - Burns and/or scarring, soreness, redness "sha" and/or bruising that may last for 3-5 days
• Dietary advice - subtle digestive changes as the body adjusts to new foods
• Gua Sha - soreness, redness "sha" and/or bruising that may last for 3-5 days
• Heat lamps - Burns and/or scarring
  
• Moxibustion - Burns and/or scarring
• Tui Na - soreness, bruising, tiredness, emotional release and skin sensitivity
• You understand and do not expect the practitioners at NRQi Studio to be able to anticipate and explain all possible risks and complications of treatment, and you wish to rely on the NRQi Studio practitioners to exercise judgment during the course of treatment, based upon known facts.
• You understand that results are not guaranteed with NRQi Studio treatments.
• You understand that the practice of acupuncture and Chinese Medicine is not an exact science and there are no guarantees that have been made to you as a result of treatment.

Infectious Disease/ Clean Needle Procedure

• You understand that infectious organisms can be carried through the air, through physical contact, and through body fluids.  You understand that my NRQi Studio practitioner uses Universal Precautions to guard against the spread of infection and will employ appropriate procedures should health and safety become compromised according to RiDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013).
• You understand that your NRQi Studio practitioner follows strict clean needle procedures and follows the Acupuncture Society Code of Safe Practice. Only sterile, single-use disposable acupuncture needles are used and are discarded in a biohazard container.

Your NRQi Studio Practitioner's Rights

• You understand that if you are deemed to be under the influence of drugs or alcohol, your NRQi Studio practitioner has the right to refuse you treatment. 
• You understand that your NRQi Studio practitioner has the right to refuse you treatment, for example, if it is deemed that your condition requires onward referral.
  

NRQi Studio's Cancellation Policy

• You understand that NRQi Studio operates a Cancellation Policy which is clearly shown on our website and you agree to the conditions of the policy.

Please note:  You understand that you are booking your NRQi Studio appointment based upon agreeing and accepting the terms and conditions of NRQi Studio's Informed Voluntary Consent Policy as described above. 

Patient Declaration:

• I confirm that I have carefully read and understood the above information related to NRQi Studio's Informed Voluntary Consent Policy and have felt free to ask questions.
• I confirm that my proposed treatment has been explained to me.
• I confirm that I understand what procedures will be used and I give my full consent to be treated in this manner. 
• I have/they have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions.
• I have been given the option to confirm my, or the person whose care I am responsible for, appointment booking.
• I confirm that I have read, or have had read to me or them, the above Informed Voluntary Consent Policy to treatment.
• I intend this consent to cover the entire course of treatment for my/their present condition and for any future condition(s) for which I/they seek treatment.
• I confirm that all the information which I have provided NRQi Studio is true to the best of my knowledge and recollection.
• I confirm that I am aged 18 years or over, or am the legal guardian or parent of a minor (under 18 years of age) who is seeking treatment.

By booking an NRQi Studio appointment, you agree to our

Informed Voluntary Consent Policy.