Intake - 30 Min Facial Acupuncture - Dr. Stefanie Greenleaf: Boulder Chinese Medicine, Acupuncture, Cupping, Tuina

Facial Acupuncture Intake Form (30 Min)

Your questionnaire provides valuable information which helps us understand the underlying causes of your health concerns. All questions contained in this history form are strictly confidential and will become part of your medical record on file.
Patient Name
First Last
Skin Care History
- Bags / Swelling Under Eyes
- Sagging Face
- Wrinkles
- Vertical Creases / Furrows
- Premature Graying of Hair
- Droopy Eyelids
- Oily Skin
- Dry Skin
- Lusterless Skin
- Acne
- Acne Scarring
- Rosacea
- Sun Damage
- Large Pores
- Broken Capillaries
- Protruding Temporal Veins
- Other
What improvements would you like to see?
Please describe any skin sensitivities or allergies:
Do you wear makeup daily?
- Yes
- No
Do you wear sunscreen daily?
- Yes
- No
Please describe your current skin care regimen and products that you use. (Toner, astringent, exfoliation, masks, etc.)
Do you go to tanning booths?
- Yes
- No
Do you participate in vigorous aerobic activity or sport?
- Yes
- No
Do you get facial waxing, electrolysis or use depilatories?
- Yes - If so, please wait 5 days between treatments
- No
Please check all procedures you have had in the past 6 months"
- Botox Injections
- Collagen Injections
- Microdermabrasion
- Chemical Peel
- Laser Procedures
Consent*
Informed Consent for Acupuncture Facial
A facial acupuncture treatment involves the insertion of acupuncture needles into fine lines and wrinkles on the face and neck in order to reduce the visible signs of aging. In Chinese Medicine, the meridians or pathways of Qi (energy) flow throughout the entire body from the soles of the feet up to the face and head; consequently, a facial acupuncture treatment addresses the entire body constitutionally, and is not merely “cosmetic.” Facial acupuncture involves the patient in an organic and gradual process that is customized for each individual. It is no way analogous to, or a substitute for, a surgical “face lift.”
Benefits
Facial rejuvenation acupuncture can increase facial tone, decrease puffiness around the eyes, as well as bring more firmness to sagging skin, enhance the radiance of the complexion and flesh out sunken areas. Customarily, fine wrinkles will disappear and deeper ones will be reduced. As this treatment is not merely confined to the face, but incorporates the entire body and constitutional issues of health.
Risks of Facial Rejuvenation Acupuncture
Every procedure involves a certain amount of risk and it is important that you understand the risks involved with facial rejuvenation acupuncture. An individual’s choice to undergo facial rejuvenation acupuncture is based upon the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your acupuncturist to make sure you understand the risks, potential complications, and consequences of facial rejuvenation acupuncture these include Bleeding, Infection, Damage to Deeper Structures, Bruising and Puffiness, Nerve Injury, Unsatisfactory Result, Allergic Reactions.
Long Term Effects
Subsequent alterations in facial appearance may occur as the result of the normal process of aging, weight loss or gain, sun exposure, or other circumstances not related to facial rejuvenation acupuncture. Facial acupuncture does not arrest the aging process or produce permanent tightening of the face and neck. Future facial acupuncture maintenance treatments, or other treatments, may be necessary to maintain the results of facial rejuvenation acupuncture.
1. I hereby authorize licensed acupuncturists Stefanie Greenleaf, LLC to perform facial rejuvenation acupuncture. I have received the INFORMED CONSENT FOR ACUPUNCTURE FACIAL.
2. I recognize that during the course of the facial rejuvenation acupuncture treatment, unforeseen conditions may necessitate different procedures than those above. I therefore authorize Stefanie Greenleaf, LLC to perform such other procedures that are in the exercise of her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my acupuncturist at the time the procedure is begun.
3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
4. I am committing to one acupuncture facial treatment at $45/ per treatment.
5. It has been explained to me in a way that I understand: a. The above treatment or exposure to be undertaken b. There may be alternative procedures or methods of treatment c. There are risks to the procedure or treatment proposed
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-5). I AM SATISFIED WITH THE EXPLANATION.
Disclaimer Informed consent documents are used to communicate information about the proposed procedure along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all- inclusive in defining other methods of care and risks encountered. Your acupuncturist may provide you with additional or different information which is based upon all the facts in your particular case and the present state of knowledge within the field of acupuncture . Informed consent documents are not intended to define or serve as the standard of acupuncture. Standards of acupuncture are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the following consent.

I agree to the Consent Form
Consent Signature*
First Last