New Patient Forms
Please download and complete the appropriate new patient forms below. All information is kept strictly confidential.
*Please Note: You may be required to fill out more than one of the forms below. If you're not sure which forms apply, please call our clinic and ask. We will be happy to assist you!
Your cooperation in filling out these forms before your first visit will help us to schedule more time for you to spend with the acupuncturist. If you cannot download and fill out these forms, you must arrive at the clinic a half an hour before your scheduled appointment time.
New Patient Intake
Women's Fertility Survey
If you are a woman seeking treatment for fertility problems, please download this form
in addition to the New Patient Intake form above.
Basal Body Temperature Chart
This is an important tool to determine your fertility quotient.
If your insurance plan offers acupuncture coverage through American Specialty Health (ASH),
which would include Kaiser and many HMOs, please download this form in addition to the New
Patient Intake form above. If you are unsure if your insurance is through ASH, please call our office and we will be happy to assist you in determining your coverage.
All information provided on this website is intended for educational purposes only. It is not meant to be a substitute for consulting with your physician.
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