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  • Acupuncture

    We would like to answer your questions about acupuncture and Traditional Chinese Medicine. Here are explanations to the some commonly asked questions. You are always welcome to ask our doctors questions about your own condition.

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  • Oriental Herbal Medicine

    Chinese Herbal Medicine As the largest organized herbal system in existence today, Chinese Herbal Medicine is a natural therapeutic modality, mostly composed of plants and minerals, which has evolved over 5,000 years of practical application and study. Not only is it a frontline intervention used in China and most of Asia, it is recognized all Continue Reading

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  • Facial Rejuvenation

    Beauty emerges from the inside out! Acupuncture Facial Rejuvenation, known in China as “Mei Rong”, is a safe, non-surgical way for both women and men to reduce signs of aging while revitalizing the whole body, so you’ll look and feel more radiant!

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  • Women’s Health

    A women’s body goes through many different cycles throughout a lifetime due to the constant change of hormones.

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  • Chronic Pain

    Acupuncture and Pain Management Millions of Americans are suffering from all kinds of pain each year. No matter how severe or minor ache these pain are, any discomfort on a part of the body could negatively affect the quality of one’s life. Pain not only frustrates and depresses the person with pain but often affects Continue Reading

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For online registration please fill out the intake form below. Or,  download & print for your convenience and fill out prior to your appointment.

Adobe_PDF_IconINTAKE
Adobe_PDF_IconHIPAA

PATIENT INTAKE FORM

First Name: *
Middle Name
Last Name: *
Age:
Birth Date:
 /  / 
E-mail:
Mailing Address:
Phone (Home):
-
Phone (Work):
-
Number of Children :
Occupation:
Employer:
Marital Status:
Emergency Contact:
Emergency Contact Phone:
Referred By:

INSURANCE INFORMATION

Do you have health insurance:
Insurance Co.:
Plan/Group:
Policy ID#:
Co-pay $:
Deductible $:
Relationship to Insured:

Information on Insured (if other than yourself)

Name of Insured:
Date of Birth:
 /  / 
Address:
Phone:
-
Secondary Insurance:
Policy ID #:
Medical History and Conditions
Health Related Information: Please list the main problems/reasons for this appointment:
Have you seen other health care providers for this? (If yes, list diagnosis and treaments):

For Injury:

Type of Injury:
Accident Place :
Describe:
Injury Date:
 /  / 
Date Symptoms Started:
 /  / 
Have you had this same condition before?:
If Yes, When?:
Series Illnesses:
Surgery:
Major accidents:
Current medications:
Current supplements/herbs:
Others:
Allergies (Medications, Food and Environment) :
Habits (Coffee, Tobacco, Alcohol & Drugs etc) or Special diet and exercises :
Are you currently pregnant?:
Do you have a pacemaker?:
HIV positive:
Any other problems you would like to discuss:

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