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New Paitient Forms

Clinic Forms

Fill In Your Information Below Prior To Your First Visit.

Patient Intake Forms

MM slash DD slash YYYY
Are you:
Select The Activities Your Problem Interferes With
Are You Interested In?
Please Mark Any That Apply
Please Mark Any That Apply
Please Mark Any That Apply
Please Mark Any That Apply
Choose Any That Apply
Select Any Illness(es) That You Have Or Have Had
Pain Intensity Level
Work - Can Do
Frequency of Pain
Recreation - Can Do
Recreation - Can Do
Check Any That Apply
Please provide details of any family members who have had any of the following conditions.
Please sign and date at your next appointment.
INABILITY TO OBTAIN ACKNOWLEDGEMENT: To be completed only if no signature is obtained. If it is not possible to obtain the individual's acknowledgement was not obtained: Patient unable to sign Patient unable to sign (inactive patient) Family/significant other not available Patient declines to sign Other ​
THE PATIENT IDENTIFIED ABOVE AUTHORIZES ACUPUNCTURE MEDICAL TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING: SPECIFIC AUTHORIZATION I give permission to Acupuncture Medical to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, information about treatment alternatives or other health related information. If Acupuncture Medical contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail. (OPEN ROOM AUTHORIZATION - OPTIONAL) I give Acupuncture Medical permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear at any time in private, the doctor will provide a room for these conversations. By signing this form you are giving Acupuncture Medical permission to use the disclose your protected health information in accordance with the directives listed. RIGHT TO REVOKE AUTHORIZATION You have the right to revoke the AUTHORIZATION, in writing at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Acupuncture Medical. The written notice must contain the following information. Name Social Security Number Date of Birth A clear statement of your intent to revoke this AUTHORIZATION The date of your request Your signature The revocation is not effective until it is received by the Privacy Official. The AUTHORIZATION is requested by Acupuncture Medical for its own use/disclosure of PHI. (Minimum necessary standards apply.) You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, Acupuncture Medical will not refuse to provide treatment. You have the right to inspect or copy the PHI to be used/disclosed. ******A COPY OF THIS SIGNED AUTHORIZATION WILL BE PROVIDED TO YOU UPON REQUEST***** ​ ​Please sign your next appointment.