Patient Forms

The following forms may be filled out at the office prior to your initial intake, or they can be downloaded here.

Required

• New Patient Form. (Some people have been having extra blank pages appear in this form; if you are having this trouble, please let me know.)
• Arbitration Agreement and Informed Consent (Please print in color)
• Please read the Privacy Policy and keep for your records.
  Acupuncture Ecology is committed to your privacy.
• Sign the Acknowledgement of Receipt of Privacy Policy.
• Also sign the Consent for Use and Disclosure of Health Information, in which you can make clear to whom you will allow disclosure of your protected health information.

 

Optional

• Birth History. This form is not absolutely required, but can be very helpful in cases of chronic illness, or conditions that originated in childhood.