Patient Information & Consent Form

Patient Details

First Name

Please enter your first name.

Last Name

Please enter your last name.

Date of Birth

Please enter your date of birth.

Email Address

Please enter a valid email address.

Phone Number

Please enter your phone number.

Gender (optional)

Address

Please enter your address.

Occupation (optional)

Company / Employer (optional)

GP / Clinic Name

NHI Number (optional)

ACC Number (if applicable)

How did you hear about us?

If Other, please specify

Emergency Contact

Name

Phone

Relationship

Services & Treatments

Meridian Osteopathy offers the following treatments. Please tick the services you consent to receive. Multiple treatments may be combined within a single consultation.

Osteopathy Manual therapy techniques and rehabilitation exercises. Specific techniques will be explained and discussed with you during your consultation.

Acupuncture (Western & Traditional Chinese) Including dry needling, auricular acupuncture, electrical acupuncture, moxibustion, cupping, and therapeutic massage (tuina).

Bio-Photomodulation / Low Level Laser Therapy For pain management and tissue recovery.

Please select at least one service.

Your practitioner will explain the treatment during your consultation. You can ask questions or decline any technique at any time.

Medical History

Please tell us if any of the following apply. If you answer Yes, a small box will open for you to share details.

Do you have any current medical conditions, injuries, or ongoing health concerns?

Yes No

Please share details (e.g. lower back pain, asthma, diabetes...)

Are you currently taking any medications or supplements?

Yes No

Please list (e.g. ibuprofen, blood thinners, supplements...)

Do you have any allergies? (including anti-inflammation cream, adhesive tape, or needles)

Yes No

Please list (e.g. anti-inflammation cream, penicillin, nickel...)

Are you pregnant or trying to conceive?

Yes No Not applicable

Please share any relevant details (e.g. weeks pregnant, fertility treatment...)

Have you had any previous surgeries or hospitalisations?

Yes No

Please list (e.g. knee surgery 2019, appendix 2010...)

Patient Responsibilities & Safety

You have selected acupuncture and/or laser therapy. To ensure your safety, please let us know if any of the following apply to you. Your practitioner will discuss any positive responses with you before treatment.

Do you have a cardiac pacemaker or other electrical implants?

Yes No

Do you have a bleeding disorder or use blood-thinning medication (e.g. Warfarin)?

Yes No

Do you have any infectious diseases or a compromised immune system?

Yes No

Do you have any metal allergies (specifically nickel)?

Yes No

Important Information for Acupuncture Patients

You have selected an acupuncture treatment. Please read the additional information below carefully.

Potential Risks & Side Effects

While acupuncture is generally safe, you should be aware of the following possibilities:

Common: Temporary soreness, stiffness, fatigue, or minor bruising at the site of needle insertion.
Rare: Fainting, nerve irritation, or a small hematoma.
Extremely rare: Pneumothorax (lung puncture) is a documented but highly infrequent risk of acupuncture in the chest or upper back area.

Pneumothorax — Emergency Symptoms

If you have received acupuncture in the chest area, please monitor yourself for the following symptoms for at least 48–72 hours post-treatment. Although symptoms most commonly appear within a few hours, in rare cases they can develop several days later:

Sudden, sharp chest pain (often on one side), especially pain that gets worse when breathing deeply or coughing
Shortness of breath or difficulty breathing
A persistent, dry cough
Rapid heart rate or a feeling of tightness in the chest

IMPORTANT: If you experience any of the symptoms above, do not contact the clinic first. Go immediately to the nearest Emergency Room (A&E) or call emergency services on 111. Inform the medical staff that you have recently undergone acupuncture treatment.

Please confirm you have read the acupuncture-specific information above.

Informed Consent

Please read the following statements carefully and tick the box at the bottom to confirm your understanding and agreement to all of them.

I understand that osteopathic treatment, acupuncture, and related therapies involve hands-on techniques, needling, and/or other physical modalities. The nature of the treatment has been explained to me.
I understand that, as with all treatments, there are potential risks and side effects, which may include temporary soreness, bruising, fatigue, light-headedness, or, in rare cases, more serious complications. I have had the opportunity to ask questions about these risks.
I confirm that I have disclosed all relevant medical history, medications, allergies, and health conditions to the best of my knowledge. I will inform my practitioner of any changes to my health.
I understand that I may withdraw my consent and discontinue treatment at any time without prejudice.
I understand that treatment may require the removal or adjustment of clothing to access the area being treated, and that draping will be used to maintain my privacy and comfort.
I consent to my personal and health information being collected and stored securely in accordance with the New Zealand Privacy Act 2020 and the Health Information Privacy Code 2020, for the purpose of my care at Meridian Osteopathy.
I understand that if I am making an ACC claim, my information may be shared with ACC as required. I consent to Meridian Osteopathy lodging ACC claims on my behalf where applicable.

Please confirm your agreement to the consent statements above.

You can ask to see or correct the information we hold about you, or withdraw your consent to its future use, at any time — contact our staff at info@meridianosteopathy.co.nz. Our Privacy Policy explains what we collect, how we use and store it, who we share it with, and your rights in full.

Is the patient under 16 years of age?

Yes No

Please tell us whether the patient is under 16.

Parent / Guardian Consent

As the patient is under 16, a parent or legal guardian must provide consent on their behalf.

Parent / Guardian Full Name

Please enter the parent or guardian's full name.

Relationship to Patient

Please enter the relationship to the patient.

Signature

Please sign below using your finger or mouse to confirm your consent.

Sign here

Please provide your signature.

Date

Patient Information & Consent Form

Patient Details

Emergency Contact

Services & Treatments

Medical History

Patient Responsibilities & Safety

Important Information for Acupuncture Patients

Potential Risks & Side Effects

Pneumothorax — Emergency Symptoms

Informed Consent

Parent / Guardian Consent

Signature

Thank You!