New Patient Intake Forms

Hello and welcome! We’re so excited to work with you!

Before your first visit, we need to know more about you and your health history. Forewarning: this is a long intake form (sorry about that), but it helps us understand more about what’s going on. Please answer all the questions, even if some of them aren’t directly related to why you’re seeking acupuncture. Thank you!

About You


Emergency Contact


Current Medications

Hang in there! You’re doing great!

Your Health History

Take a deep breath, you’re almost there!


Female Only: Gynecology/Pregnancy


Male Urology/Sexual Function

You’re in the home stretch!

Family Medical History

Phew, you made it through the intake. Nicely done! Now please take a moment to view and read the consent forms. Don’t worry, there’s no need to print these out, unless you want to.

Electronic Signature

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