Please print out these forms, fill them in, and bring them to your first appointment

Please do not print the forms on both sides of the page.

General Acupuncture  – these are the forms needed by most patients

Women’s Health Acupuncture – women who are seeking treatment for infertility, menopause, menstrual problems, or other hormonal issues should fill out this form set

Pediatric Acupuncture – please fill out these forms for patients age 14 and under (patients over the age of 14 should fill out the general form above)

Cupping – please fill out these forms if you have made an appointment for cupping only (no acupuncture)

Addiction Acupuncture – patients who are seeking treatment for smoking cessation and other addictions should fill out this set of forms

You will need Adobe Acrobat Reader to download and print your forms. If you do not have Adobe Reader, you can get it here:

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