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acupuncture1(2)_web.jpg
acupuncture1(2)_web.jpg
acupuncture1(2)_web.jpg

booking form


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booking form


Personal Information
Name *
Name
Phone *
Phone
Address
Address
optional
Appointment Information
Preferred Date 1
Preferred Date 1
Preferred Time
Preferred Time
Preferred Date 2
Preferred Date 2
optional
Preferred Time
Preferred Time
I am looking to treat
please select all that apply
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intake form


intake form


Please fill out and submit the form below at least 24 hours before your first appointment.  

New Client Intake Form
Name *
Name
Todays Date *
Todays Date
Date of Birth *
Date of Birth
Address *
Address
Telephone (home) *
Telephone (home)
Telephone (work)
Telephone (work)
Allergies
Health Checklist
please check all symptoms/disease that apply to you.
please check all symptoms and disease that apply to you *
Do you have a pacemaker?
Females
Please select all that apply
What colour is the period blood-Menses?
Please select all that apply
Males
Please select all that apply
I hereby agree to the Acupuncture Consent Form and its contents listed below
I hereby agree to the Acupuncture Consent Form and its contents listed below
your "signature"

Acupuncture Consent Form

I hereby agree and consent to the performance of Acupuncture, Traditional Chinese Medicine and related modalities performed by a Registered Acupuncturist. I understand that such procedures may include, but are not limited to: Acupuncture, Moxibustion, Cupping, Electrical Acupuncture, Gua sha, Tuina.

I understand that while generally painless there are possible side effects from the above mentioned treatments such as: bruising, numbness or tingling, dizziness or fainting, weakness, tiredness, nausea, minor swelling, bleeding, temporary pain or discomfort, hematoma at puncture site or blistering at Moxabustion site.  A sensation of light-headedness may occur after acupuncture treatment and/or temporary aggravation of existing symptoms.

By voluntarily signing below I hereby certify that I have read this entire form, have been informed about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions with regards to the modalities described above.  Additionally, I have consulted with a physician or dentist (as appropriate) about the condition for which acupuncture treatment is now being sought.

I intend this consent form to cover the entire course of treatment to be performed for my present condition and for any future condition(s) for which I seek treatment. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify or change the treatment plan.

I understand that there is a 24 hour cancellation policy.  I may be charged up to the full cost of treatment if I miss or cancel an appointment with less than 24 hours notice.

  


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intake form download


intake form download


 

Click on the image below to download the Intake Form. Please print and complete the form before your appointment.