New patient form

Medical history & consent

Please complete this short form before your first visit. It takes about three minutes and helps your practitioner plan a safe, personalised treatment. Your answers are stored confidentially in the clinic's patient record system and handled in line with our privacy policy.

Your details

Full name *

Date of birth

Phone

Reason for your visit

Main complaint or symptoms *

How long have you had it?

What would you like treatment to achieve?

Medical history

Current or past medical conditions

Medication or supplements

Allergies

Operations or serious injuries

Pregnancy

Chinese medicine check

Sleep

Digestion

Energy

Stress

ConsentI consent to acupuncture and related Chinese medicine treatment. I understand the common temporary effects (minor bruising, tiredness or light-headedness) and confirm the information above is accurate.I consent to AcuZen London storing and processing my health information to provide my care, as described in the privacy policy.Optional: I'm happy to receive clinic news and offers by email. I can unsubscribe at any time.

Signature — type your full name *

Signed electronically and dated 04/09/2026.