טופס קבלת מטופל

    Welcome to Gil Ton AcuMed clinic 🙂 please fill-out the registration form below and sign it. Thank you


    *Full name (required)


    *Your email (required)


    *Contact number (required)


    *Date of birth (required)


    Gender


    *Full address (required)


    Chief complaints (duration, symptoms, location) you'd like to address for the appointment


    Please describe your key present health issues and their duration including a diagnosed diseases


    Please write down your medications, vitamins and herbal medicine you use, which include dose and duration

    You are asked to write Yes / No in the appropriate question:


    1. A patient with a known chronic pain that comes with a new or different type of pain:


    2. Edema in an organ that has not been diagnosed in an healthy person:


    3. General edema (a weight gain over a kilo a day):


    4. Any new chest pain with unknown reason:


    5. Chest pain for no apparent reason:


    6. New heart palpitation (fast-beating), irregular or unexamined heartbeat:


    7. Severe shortness of breath:


    8. Enlarged or swollen gland / lymph nodes not as a result of acute viral or bacterial infection:


    9. Acute and fixed abdominal pain that does not change over time:


    10. Nausea and vomiting with background of a head trauma or heart disease:


    11. Severe constipation with a suspect for intestinal obstruction:


    12. Multiple haematoma, or blood suffusion in the body without any explanation:

    13. Acute joint pain that includes one of the following:


    Skin infection:


    Local heat:


    Local swelling:


    Redness:


    Movement restriction:

    16. Back or neck pain which was not diagnosed by a doctor:


    Radiating pain:


    Altered pain sensations:


    Pain that worse at night:


    Trauma (whiplash):


    Osteoporosis:


    17. A cancer related diagnosis in the last five years:


    18. Unstable blood pressure:


    19. Candidate for surgery:


    20. Illness, previous hospitalization or taking medications that are not clear to me:


    21. Any doubt that I can not receive a treatment


    If one of the answers is yes, please specify

    Signature: By signing this, I understand that the provided treatment (Acupuncture, Laser Acupuncture, Chinese herbal medicine) is part of Chinese medicine treatment modalities for the purpose of helping me to improve my health and wellbeing. As well, I understand that Dr. Gil Ton Ph.D is not a General Practitioner in the Netherlands and the treatment is not a substitute for medical diagnosis or treatment, which if needed I'll contact the General Practitioner.

    Please Note:

    1. The treatment for children requires the consent of both parents with custody according to the law.
    2. Cancelation policy: Please contact Gil Ton by email or phone at least 24 hours in advance to cancel or reschedule your appointment otherwise you'll be charged for the appointment. Thank you for your time and understanding.
    3. Wear comfortable clothing and eat before the treatment ( it is recommended not to have a session on an empty stomach).


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