If you are a new patient, please fill out the form below. If you are a returning customer, please feel free to contact me here to book an appointment.

New Patient Intake Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Date of Birth

YYYY

Relationship Status

Employment Status

Occupation

Emergency Contact/Relation to Self

Emergenct Contact Phone Number

(###)

###

####

Physician's Name

Physician's Phone Number

(###)

###

####

Insurance Company

Member Policy Number

Are you the primary policy holder?

Yes

If primary insured is different please provide their name and date of birth

I am an out of network acupuncturist and sessions must be paid in full at time of service. Every insurance plan has different benefits but if you would like a superbill to submit for possible reimbursement, let me know below.

Please describe your reasons for coming to see me and any details that you feel may be relevant or helpful for me to know.

Please tell me about your medical history including and major illness or accident, and any medications or supplements you are currently taking.

Are you interested in learning about Cosmetic Acupuncture and/or Microneedling?

Is there anything else that you would like to share with me that you feel is important or beneficial for me to know about you?

New Patient Intake Form

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