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Patient Intake

Welcome to our clinic. To provide you with the most effective and personalized care, please complete the following health assessment form. Your detailed history helps us understand your unique path to wellness. All information provided is confidential and used solely to tailor your acupuncture treatment plan.

Patient Intake Form

Please complete this comprehensive questionnaire to help us understand your health history and current goals. Your responses are confidential and vital to personalizing your acupuncture treatment plan.

Acupuncture Intake Form

Please complete this form before your appointment. Your information will be kept strictly confidential.

Date of birth
Month
Day
Year
Gender
Male
Female
Non-binary
Prefer not to say
Home address

Consent to Treatment

By signing this form, you acknowledge that acupuncture and other Traditional Chinese Medicine (TCM) procedures involving the insertion of needles or other treatments like cupping and Gua Sha are elective. While generally safe, these procedures may result in minor bruising, lightheadedness, or temporary soreness. You consent to these treatments and affirm that you have provided a complete medical history to your provider. This agreement remains in effect for all future sessions unless revoked in writing.

Clinic Policies

To ensure all patients receive the best possible care, we require at least 24 hours' notice for all cancellations or rescheduling. Cancellations made with less than 24 hours' notice will be subject to a cancellation fee of 50% of the service cost. No-shows will be charged the full service amount. We thank you for respecting our practitioners' time. Please arrive 10 minutes prior to your first appointment to finalize any remaining paperwork.

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