Indemnity Release and Information Form

The Teaching Clinic was established to enable SITCM students to practise the Acupuncture and Chinese Herbal Medicine skills they have learned. It is supervised by qualified and experienced Clinic Supervisors.

Tele-consultations generally last 45 minutes in total, and include one student-in-charge (a senior student) and observing students. To reach a diagnosis, the student-in-charge will ask you a range of personal questions and check your tongue. The supervisor may then ask further clarifying questions. Once a diagnosis has been reached, the supervisor will review and approve an appropriate treatment plan. The student-in-charge will then provide you with a herbal prescription and price estimate. If you would like the herbs (which are available as granules or pills only), they will be delivered to your address as soon as possible after the consultation. You will need to pay for the herbs by bank transfer after the tele-consultation. If you do not wish to buy the herbs, then your tele-consultation will be completely free. No physical treatments (e.g., acupuncture, cupping, etc) are available for tele-consultations.

To protect patient privacy, tele-consultations are never recorded. After the consultation, the student-in-charge will send your patient record to the clinic manager, who will file it at our Teaching Clinic after the lockdown ends. Your patient record will not be sent to anyone else without your express permission.

Herbal medicine may sometimes cause side effects that include but are not limited to nausea, vomiting and diarrhea. Pre-existing conditions may cause other adverse events. All adverse events should be reported to the Student-in-Charge or Supervisor. On rare occasions where an adverse event is serious, contact the Poisons Information Centre (phone 13 11 26), a general practitioner, or an ambulance (or all three). If the adverse event appears to be due to a reaction to a herbal medicine, also contact the TGA (phone 1800 044 114). Chinese medicine treatments should not be construed as a substitute for conventional medical examination or treatment.

The Supervisor on duty will be more than happy to answer any questions you may have.

    I,(if patient is under 18, please give parent/guardian name), declare that I have read, understood and freely consent to all conditions set out above. I confirm that I have stated all known medical conditions and answered all Patient Information Form questions honestly to the best of my ability.

    I agree to receive occasional email updates about the SITCM Clinic.

    Patient:Parent or Guardian (If patient under 18 years of age):

    Please use English. All information is confidential. Any changes must be advised in future visits.

    Personal Information

    Medical History