Purpose of voluntary consent
I hereby request and consent to the performance of Acupuncture treatments and other procedures within the scope of the practice of Acupuncture on me, on my child, a child that is in my care, or on the patient for whom I am legally responsible.
I hereby voluntarily consent to be treated with Acupuncture by Glenn Delikan. I understand that I may be treated with the application of insertion of sterile acupuncture needles and/or finger pressure and/or the application of heat to the skin and/or Cupping/Gua Sha and/or Chinese dietary therapy.
I understand that the practice of Acupuncture is not an exact science and there are no guarantees that have been made to me as a result of treatment.
Possible side effects/ healing response
I have been informed that Acupuncture is a generally safe method of treatment, but that it may have some side effects including: bruising, numbness or tingling near the needle sites that may last a few days and dizziness or fainting. Burns and /or scarring are a potential risk of Moxibustation and Cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of Acupuncture include: spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although sterile disposable needles are used with all patients to maintain the safest and most sterile treatment environment possible.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment, based upon the facts then known is in my best interest. I understand that results are not guaranteed.
I understand the clinical and administrative staff may review my patient records, but all my records will be kept confidential and will not be released without my written consent.
I understand that if there is a worsening of my ailment or condition, or if it does not improve within the time estimated by my practitioner, or if a new ailment or condition arises, that I should consult my GP. If you request that Glenn Delikan discuss or share his records of your case with another healthcare provider he will gladly do so provided that you have given him written permission. This is a professional standard among all licensed healthcare providers.
Infectious Disease/ Clean Needle Procedure
I understand that infectious organisms can be carried through the air, through physical contact, and through body fluids. I understand that my Acupuncture practitioner uses Universal Precautions to guard against the spread of infection. I understand that Glenn Delikan follows strict clean needle procedures. Only sterile, single-use disposable Acupuncture needles are used and are discarded in a biohazard container.
I understand that it is my responsibility as a patient to inform Acupuncturist practitioner Glenn Delikan about all aspects of my health and that as treatment progresses, to inform my practitioner of any changes that occur. I have carefully read and understand the above information. I am aware of what I am agreeing to and have felt free to ask questions.
CONSENT TO TREAT A MINOR CHILD
I authorise Glenn Delikan to administer Acupuncture as deemed necessary to my child or a child in my care.
Reasonable suspicion that the Clinic has been exposed to COVID-19 or other infectious diseases
If a person who has visited the clinic is diagnosed with Covid-19 within 14 days from my last contact with them I will take the following steps and precautions.
If myself or a staff member at any time had a proximity to this person under two metres or were exposed to a cough or sneeze, I will stay home for seven days from my last contact with them and only return to work if neither of the three cardinal symptoms of Covid-19 have not appeared (as defined in Appendix 2 of the BAcC guide to COVID-19).
If either myself or a staff member is diagnosed with Covid-19 under 14 days or less after non-socially distanced contact with a patient I later discover has also been diagnosed with Covid-19 in the same period, I will follow the HSE guidance regarding Covid-19 and RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013).
Additionally I will inform all patients who had been present during the suspected exposure period and cancel all future appointments until I have followed all the steps outlined in Section 3 of the BAcC guide to COVID-19.
If I have reasonable suspicion that the practice premises have been exposed to a person with a case of Covid-19, all access to the building must be suspended until a deep clean can take place.
This also applies if I am informed by other users of the premises that they have reasonable suspicion that the building has may have been exposed.
Purpose of privacy notice
The processing of personal data is governed by the General Data Protection Regulation 2016/679 (the GDPR). This legislation will replace current data privacy law, giving more rights to you as an individual and more obligations to organisations holding your personal data.
One of the rights is a right to be informed, which means I have to provide you with information about the way in which I use, share and store your personal information.
This means that I will be publishing a new privacy notice so you can access this information, along with information about the increased rights you have in relation to the information I hold on you and the legal basis on which I am using it.
This new privacy notice comes into effect on 25 May 2018.
Who am I?
Glenn Delikan is the data controller. This means I decide how your personal data is processed and for what purposes.
Whose information does this privacy notice apply to?
This privacy notice applies to information I collect from:
• prospective patients;
• former patients;
I am required to keep these records for seven years from the date of the end of treatment.
What is personal data?
Personal data relates to a living individual who can be identified from that data. Identification can be by the information alone or in conjunction with any other information in the data controller’s possession or likely to come into such possession. Examples of personal data I may hold about you include your contact and appointment details.
Special category data is a sub-category of personal data which includes racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person’s sex life or sexual orientation. For my purposes, the special category of data I may hold about you is solely your patient notes.
How do I process your personal data?
I comply with my obligations under the GDPR by keeping personal data up to date; by storing and destroying it securely; by not collecting or retaining excessive amounts of data; by protecting personal data from loss, misuse, unauthorised access and disclosure and by ensuring that appropriate technical measures are in place to protect personal data. I use your personal data for the purposes set out below.
Sections 1 – 15 apply to my patients, prospective patients, former patients and visitors to my clinic
1 - I use your name, address, telephone number and email address to make and rearrange appointments. I are unable to send or receive encrypted emails so you should be aware that any emails I send or receive may not be protected in transit. I will also monitor any emails sent to me, including file attachments, for viruses or malicious software. Please be aware that you have a responsibility to ensure that any email you send me is within the bounds of the law.
2 - I will use your name, address, telephone number and email address, only if I have your explicit consent, to send you marketing materials. I am unable to send or receive encrypted emails so you should be aware that any emails I send or receive may not be protected in transit. I will also monitor any emails sent to me, including file attachments, for viruses or malicious software. Please be aware that you have a responsibility to ensure that any email you send me is within the bounds of the law.
3 - Some patients and prospective patients return pre- 1st appointment questionnaires or tell me about their medical conditions and medication by email or online enquiry forms. I are unable to send or receive encrypted emails so you should be aware that any emails I send or receive may not be protected in transit. I will also monitor any emails sent to me, including file attachments, for viruses or malicious software. Please be aware that you have a responsibility to ensure that any email you send me is within the bounds of the law.
4 - I keep an attendance register which records appointments for patients attending my clinic to keep a record of when you were treated for tax purposes and to secure potential evidence in the event of a criminal prosecution, civil litigation, insurance claim or complaint to my regulatory body, the British Acupuncture Council.
5 - I may use your date of birth to help identify patients with the same name to avoid mistakes being made as to safe and appropriate treatment, for identification purposes if referring a patient to another health practitioner, and for identification purposes if writing to a registered medical practitioner so that they correctly identify the patient.
6 - I use your presenting complaint and symptoms reported by you for the purposes of making a full traditional diagnosis, formulating treatment strategy and treatment planning.
7 - I use any relevant medical and family history you have told me for making a full traditional diagnosis, formulating treatment strategy and treatment planning.
8 - I use your GP’s name and address in the event that I need to contact your GP including in an emergency and because it is a mandatory requirement in the British Acupuncture Code of Professional Conduct.
9 - I use my clinical findings about your health and wellbeing for making a full traditional diagnosis, and formulating treatment strategy and treatment planning.
10 - I keep a record of and refer to that record of any treatment given and details of progress of your case, including reviews of treatment planning to enable me to: review the full traditional diagnosis, treatment strategy and planning; and to secure evidence in the event of criminal proceedings, civil litigation, an insurance claim or complaint.
11 - I record and use any information and advice that I have given, especially when referring patients to any other health professional, to help you to receive the most appropriate treatment and to secure evidence in the event of criminal proceedings, civil litigation, an insurance claim or complaint.
12 - I record any decisions made in conjunction with you to help you to receive the most appropriate treatment and to secure evidence in the event of criminal proceedings, civil litigation, an insurance claim or complaint.
13 - I keep accident records for any patients, visitors or staff who are involved in accidents at my clinic in accordance with UK Health and Safety legislation including the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) to comply with the law and to secure evidence in the event of criminal proceedings, civil litigation, an insurance claim or complaint.
14 - In the event of an adverse incident occurring to any of my patients I report the matter to the British Acupuncture Council and my insurance company to enable the insurance company to deal with any potential claims and to help the British Acupuncture Council to develop its safe practice guidelines, as well as providing research data and information for the BAcC’s insurers and other interested parties.
15 - Where relevant I maintain records of the patient’s consent to treatment, or the consent of their next-of-kin in order to be able to prove that the patient (and/or parent/guardian/next of kin) has given informed consent to treatment to secure evidence in the event of a civil claim, criminal prosecution, insurance claim or complaint.
Section 16 applies to those who complain about my services
16 - I aim to provide you with the best quality treatment that I can. This includes working with your feedback to each treatment to continuously adjust the treatment to your needs. In this way I aim for us to work well as a team always.
Should you ever feel the need to make a complaint I make up a file containing the details of the complaint. This normally contains the identity of the complainant and any other individuals involved in the complaint.
I will only use the personal information I collect to process the complaint and to check on the level of service I provide. I usually have to disclose the complainant’s identity to whoever the complaint is about. If a complainant doesn’t want information identifying him or her to be disclosed, I will try to respect that. However, it may not be possible to handle a complaint on an anonymous basis. I may need to provide personal information collected and processed in relation to complaints to the British Acupuncture Council or my insurance company.
I will keep personal information contained in complaint files in line with my retention policy. This means that information relating to a complaint will be retained for two years from closure. It will be retained in a secure environment and access to it will be restricted according to the ‘need to know’ principle.
Similarly, where enquiries are submitted to me I will only use the information supplied to me to deal with the enquiry and any subsequent issues and to check on the level of service I provide.
I store and transport my records electronically.
Sharing your personal data
Your personal data will be treated as strictly confidential, and will be shared:
• with named third parties with your explicit consent;
• with the relevant authority such as the police or a court, if necessary for compliance with a legal obligation to which I are subject e.g. a court order;
• with your doctor or the police if necessary to protect your or another person’s life;
• with the police or a local authority for the purpose of safeguarding a children or vulnerable adults; or
• with my regulatory body, the British Acupuncture Council, or my insurance company in the event of a complaint or insurance claim being brought against me; or
• my solicitor in the event of any investigation or legal proceedings being brought against me.
For further details about the situations when information about you might be shared please see the Information Commissioner’s Website at
How long do I keep your personal data?
I keep your personal data for no longer than reasonably necessary.
I keep patient records for a period of 7 years in accordance with the British Acupuncture Code of Professional Conduct
I keep your record up to date by monitoring your progress when we discuss your treatments and health.
I destroy any records kept in hard copy by shredding all such data when it is no longer required. I destroy any records kept electronically by permanently deleting such data when it is no longer required.
If I am ill such that I am unable to treat you, I will pass any data to another acupuncturist whom you have decided to be treated by. You will have to give me written permission before I can do this.
When I die, I will authorise my personal representative to transfer any data concerning you to another acupuncture whom you have decided to be treated by. If you do not give written permission for this within three months of my death, my personal representative will securely destroy my records concerning you.
At any time you may request that changes are made to your contact details.
Your rights and your personal data
Unless subject to an exemption under the GDPR, you have certain rights with respect to your personal data as set out below.
The right to request a copy of your personal data which I hold about you.
The right to request that I correct any personal data if it is found to be inaccurate or out of date.
The right to request your personal data is erased where it is no longer necessary for me to retain such data.
The right to withdraw your consent to the processing at any time. This right does not apply where I are processing information using a lawful purpose other than consent.
The right to request that I provide you with your personal data and where possible, to transmit that data directly to another data controller, (known as the right to data portability).
The right, where there is a dispute in relation to the accuracy or processing of your personal data, to request a restriction is placed on further processing.
The right to object to the processing of personal data, where applicable.
The right to be informed if your data is lost. I shall also inform the Information Commissioner’s Office in accordance with the time limits in the GDPR.
The right to lodge a complaint with the Information Commissioner’s Office.
For further details about these rights please see the Information Commissioner’s Website at
If I wish to use your personal data for a new purpose, not covered by this Privacy Notice, then I will provide you with a new notice explaining this new use prior to commencing the processing and setting out the relevant purposes and processing conditions. Where and whenever necessary, I will seek your prior consent to the new processing.
To exercise all relevant rights, queries of complaints please in the first instance contact me at or by a message to 07954 013 156.
You can contact the Information Commissioners Office on 0303 123 1113 or via email or at the Information Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire. SK9 5AF.