Holistic Wellness Center

Personal Information

First Name:

Last Name:

Phone:

Email Address:

Date of Birth:

Status:

Gender:

Health Information

Male

I do not have clotting issues.

I am not HIV positive.

I do not have Hepatitis B or C.

I do not have any health problems.

I agree and accept

Health Information

Female

I do not have clotting issues.

I am not HIV positive.

I do not have Hepatitis B or C.

I do not have any health problems.

I agree and accept

What are the underlying reasons for your preference for this treatment?

Risks and Information

** Leech Therapy Consent and Disclaimer Form **

** Consent and Acknowledgement **

Please read the following information carefully and check the boxes to indicate that you understand and accept each statement.

1. ** Historical and Traditional Context **

I understand that leech therapy has historical roots and is used in various cultures to improve blood circulation, reduce pain, and enhance overall health. This treatment method is voluntarily chosen.

2. ** Voluntary Acceptance **

I declare that I participate in this therapy of my own will and voluntarily accept it. This decision has been made entirely of my own free will.

3. ** Risk of Infection **

I acknowledge that small wounds opened on the skin during leech therapy carry a risk of infection, which can lead to bacterial infections with symptoms like redness, swelling, pain, and inflammation.

4. ** Allergic Reactions **

I understand that allergic reactions may develop against substances secreted by leeches, manifesting as redness, itching, swelling, and rash. Severe allergic reactions can lead to anaphylaxis, requiring immediate medical intervention.

5. ** Bleeding and Hematoma **

I acknowledge that bleeding and bruising (hematoma) can occur on the skin after leech therapy, and while generally mild, they can sometimes turn into more serious bleedings.

6. ** Nerve and Vascular Damage **

I understand that nerves or blood vessels in the areas where leeches are placed can accidentally be damaged, leading to symptoms like loss of sensation or tingling (nerve damage) or excessive bleeding (vascular damage).

7. ** Psychological Effects **

I acknowledge that the appearance of leeches and the blood-sucking process can cause psychological discomfort, including fear of seeing blood or experiencing pain.

8. ** Blood Disorders and Other Health Issues **

I understand that leech therapy can be dangerous for individuals with bleeding disorders, such as hemophilia, and can worsen the condition of individuals with chronic diseases.

** Health Declaration **

Please check the boxes to indicate that you do not have any of the following conditions::

Bleeding Disorders (e.g., hemophilia, von Willebrand disease)

Extreme Sensitivity or Allergy to leech bites

Circulatory Problems

Diabetes

Undergoing Chemotherapy or Radiotherapy

Skin Diseases (e.g., infected or ulcerated skin problems)

Pregnancy

Children (higher sensitivity)

** Leech Therapy Pre and Post Instructions **

Leech Therapy I agree to follow the instructions below before and after the treatment.:

** Leech Therapy Before: **

I will stop using blood-thinning medications at least 3 days before the appointment.

I will avoid blood-thinning foods (e.g., lemon, sour cherry).

I will not apply perfume, cosmetic products, or gel to the treatment area.

I will not wash or moisturize my body with soap before the treatment.

** Leech Therapy After: **

I acknowledge that bleeding can continue for 24 hours in the area where leeches are applied.

I will avoid heavy work for 12 hours after the treatment.

If I feel itching, I can use an antihistamine upon the doctor’s recommendation.

I understand that infection may rarely develop and antibiotic use should be done upon doctor’s recommendation.

I will change the application bandage 24 hours later.

I can take a warm shower 24 hours later.

I will not consume alcoholic beverages after the treatment.

I will focus on a protein-rich diet (e.g., meat, chicken, fish, milk, cheese).

I will drink plenty of fluids and avoid strenuous exercise after the treatment.

** Additional Precautions and Information **

I declare that I have accurately reported my entire medical history and current health status before undergoing leech therapy.

If I experience any unexpected side effects or complications during or after leech therapy, I will seek medical assistance immediately and inform the treatment center.

I am aware that there are alternative treatment options available besides leech therapy, and I have chosen this treatment method of my own free will.

** Consent and Acknowledgement **

By signing below, I declare that I have been informed about the risks and damages mentioned above and that I accept these risks. I also declare that I have signed this form of my own free will. I accept that I will not sue the leech therapy center for any adverse situation that may occur during and after the leech therapy.

First Name Last Name:

Date:

Signature:

Emergency Contact Name:

Emergency Contact Information:

I agree and accept

Where would you like to receive the service?:

Address

Appointment Information

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