TEMPE COMMUNITY ACUPUNCTURE (480)
|
|
- Everett Jacobs
- 5 years ago
- Views:
Transcription
1 TEMPE COMMUNITY ACUPUNCTURE (480) Welcome to Tempe Community Acupuncture! TCA is one of many community acupuncture clinics established in the country who are members of POCA, a multi-stakeholder cooperative whose mission is to make acupuncture affordable for nearly everyone; while promoting a sustainable business model that works for patients and practitioners. To jump on board, learn more about the cooperative and to find POCA member clinics near you, visit We Have a Sliding Scale We offer treatments on a sliding scale of $15-$35 with an additional one-time $10 new patient fee for the first appointment. You decide what you can afford. There is never any need to prove your income. Acupuncture is most effective for current health concerns when it is done frequently and regularly. We've found this to be especially true at the beginning of a course of treatment. Acupuncture is a PROCESS. It is very rare for any person to be able to resolve a problem completely with one treatment. Frequent treatment is much more likely to lead to relief. Your acupuncturist will suggest a course of treatment based on the intensity and duration of your health concern. If you don t come in often enough or for enough treatments, acupuncture may not work as well for you. We Treat in a Community Room We believe a group setting has many benefits: it s easier for friends and family to come in together and it allows patients to keep their needles in as long as they want. Most people learn after a few treatments when they feel 'done' or 'cooked'. This can take anywhere from twenty minutes to an hour or two. The treatment room is meant to remain a quiet space for you and others to rest, sleep and let the acupuncture do its thing. Its atmosphere exists through our patients relaxing together. Maintaining this reservoir of calm requires very little talking in the clinic space including us. It is also important to turn cell phones completely off before entering the community room. Lights from phones can be just as distracting as noises. Thank you and we look forward to working with you!!!
2 HEALTH HISTORY TEMPE COMMUNITY ACUPUNCTURE (480) PATIENT INFORMATION Name Address CONTACT INFORMATION Telephone City, State, Zip Age Birthdate Emergency Contact Occupation Primary physician Primary physician telephone Name Relationship Telephone How did you hear about us? HEALTH HISTORY What are your primary concerns for coming in for treatment? How is your sleep? How is your digestion? List all medications or vitamins that you are currently taking. List all serious illnesses, accidents, or surgeries.
3 HEALTH HISTORY Check symptoms you have had in the last year: o Depression o Difficulty concentrating o Dizziness o Excessive worry o Excessive fear o Excessive anger o Fatigue o Headaches o Nervousness/irritability Check conditions you have had in the past: o AIDS o Allergies o Anemia o Arthritis o Bleeding disorders o Breast lump o Cancer o Diabetes o PCOS Please check all that apply: o Tremors o Swollen joints o Pain o Asthma o Blurred/failing vision o Difficulty breathing o Earache o Eye pain o Frequent colds o Allergies/ hay fever o Nose bleeds o Hearing loss o Cough o Ringing in ears o Bruise easily o Dry skin o Itching/rash o Sore that won t heal PAGE 2 Please check all that apply: o Blood/pus in urine o Frequent urination o Kidney infection/stones o Low libido o Chest pain o High or low blood pressure o Pain over heart o Poor circulation o Previous heart attack o Rapid/irregular heart beat o Gas or bloating o Constipation o Diarrhea o Distention of abdomen o Excessive hunger o Gallbladder trouble o Hemorrhoids o Indigestion o Nausea o Stomach pain o Poor appetite o Vomiting o Erection difficulty o Prostate trouble o Bleeding between periods o Clots in menses o Excessive menstrual flow o PMS o Irregular cycle o Menopause o Miscarriage o Light menstrual flow Could you be pregnant? SIGNATURE By signing below I agree that the information on this form is correct to the best of my knowledge. SIGNATURE DATE.
4 TEMPE COMMUNITY ACUPUNCTURE (480) Payment is due at the time of service and may be paid by cash, check, Visa, Mastercard or American Express. There will be a $35 fee for any returned checks. In order to keep our rates affordable, we do not file insurance claims of any kind and are not a Medicare/Medicaid provider. We can provide you with a receipt that you may present to your insurance provider. Cancellation Policy Tempe Community Acupuncture works to make our services available to as many people as possible, and at the most affordable rates. With respect to this goal we ask for 12 hours advance notice if you need to cancel or reschedule an appointment. You may cancel or reschedule an appointment by phone or by using our online scheduling system. You may also send us an or leave us a voic outside of normal business hours. Please note that there is a $10 cancellation fee for missed appointments or appointments that are cancelled/rescheduled with less than 12 hours notice. Thank you for your understanding. I affirm that I have read the payment and cancellation policies and that I am aware of the $10 cancellation fee for late cancellations and missed appointments. Patient s Name Date Signature Payment Policy
5 INFORMED CONSENT Informed Consent to Acupuncture Treatment I, the undersigned, hereby request and consent to treatment by acupuncture and/or other procedures within the scope of the practice of Oriental Medicine. I am hereby informed that the treatment methods are all generally safe, but there may be some side effects or risks. Acupuncture involves the insertion of special needles into particular points on the body. There are some risks to treatment, including bruising of the skin and/or slight bleeding, weakness, fainting and aggravation of symptoms existing prior to acupuncture treatment. As with any invasive procedure there is a risk of puncturing organs (this is extremely rare). At the site of the needle insertion there may be soreness, numbness, tingling, or swelling. There is a small risk of infection at the needle site. TCA uses only one-time use, sterile disposable needles. We do not reuse needles, even at different areas of the body for the same person. The herbal supplements recommended at TCA are generally mild and very safe. There are possible side effects including: nausea, gas, stomachache, diarrhea, and headache. I understand I must stop takin my herbs and notify the clinic immediately if I experience any discomfort or adverse reactions. We do not provide primary care, nor Western (allopathic) medical care. Please see your medical doctor for those services and for routine check-ups. If you are pregnant, have a bleeding disorder, pacemaker, high blood pressure, local infection or have been prescribed anticoagulant medications like Coumadin, by signing below you state that you have informed your acupuncturist of such conditions. The procedures have been explained to me and I understand that I have the right to refuse any part of treatment. I understand that I can discuss risks and benefits further with my practitioner before signing if I so choose, although I do not anticipate and expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her judgment in my best interest during course of treatment, based upon the facts then known. Although I am aware that acupuncture and other procedures within Oriental Medicine have helped millions of people, I understand that no guarantee of cure of improvement in my condition is given or implied. I have read, or have had read to me, this informed consent form. I have also had the opportunity to ask questions about its content, and by signing below, I agree to a course of treatment in Oriental Medicine. I intend this consent form to cover my entire course of treatment for my present condition and for any future condition(s) for which I seek treatment with this practitioner. I understand that the treatment here is not a replacement for medical care. With this knowledge, I voluntarily consent to the above procedures. Patient s Name Date Signature
NE COMMUNITY ACUPUNCTURE & Wellness Center
NE COMMUNITY ACUPUNCTURE & Wellness Center 1224 2 ND ST NE SUITE 201 MINNEAPOLIS MN 55413 612.399 6322 WWW.NECOMMUNITYACUPUNCTURE.COM Health History Questionnaire and Registration PATIENT INFORMATION Name
More informationPhoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.- INFORMED CONSENT Acupuncture involves the insertion of special needles into particular
More informationWelcome to Our Community!
Welcome to Our Community! Please take a minute to read this introduction to our clinic and to our community. We are delighted that you are interested in joining us! What is different about the WCA clinic?
More informationWelcome to Our Community!
Welcome to Our Community! Please take a minute to read this introduction to our clinic and to our community. We are delighted that you are interested in joining us! What is different about the GMCA clinic?
More informationNew Patient Packet Please bring with you to your first appointment.
New Patient Packet Please bring with you to your first appointment. Welcome to Hollywood Community Acupuncture! Gentle, Effective, Affordable Health Care for All of Us! Located in the Heart of Hollywood:
More informationWELCOME TO STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE!
WELCOME TO STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE! This packet contains the Welcome Letter with information on what to expect at your first appointment, the Fee Schedule, and the Patient Health
More informationPatient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
More informationName: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
More informationConsent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
More informationPATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
More informationChinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
More informationACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
More information(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
More informationKEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
More informationReason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
More informationDate of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
More informationPlease have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
More informationCASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
More informationRachel Beth Dorfman, L.Ac., C.M.T.
Rachel Beth Dorfman, L.Ac., C.M.T. Classical Acupuncture, Chinese Medicine and Asian Bodywork Patient Information Name: Today's date: Address: Age: Date of birth: City: State: Zip: Email: Best phone to
More informationAcupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
More informationWELCOME. Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally.
WELCOME Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally. Before your Visit: You should eat a light meal or snack
More informationCHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
More informationCHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
More informationJohanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
More informationPlease Read First. Thank you for your time in advance, and I look forward to working with you to achieve your optimum health.
Please Read First Dear New Acupuncture Patient, Thank you for making an appointment with me to begin improving your health with acupuncture. I congratulate you on your decision to take steps toward improved
More informationNew Patient Information
New Patient Information Name Today s Date Address Apt. City State Zip Preferred Phone Email Birth Date (mm/dd/yy) Age Gender Occupation Employer Referred by Emergency Contact: Name Phone Health History
More informationAvery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
More informationBerkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212
Initial Intake Form: Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212 ( 3 0 3 ) 3 5 1-1 2 2 8 Name: Phone: Address: City: State: Zip: E-mail: Would you like to be added to our E-Mail newsletter
More information1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
More informationDiana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify
More informationNew Patient Information
Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
More informationEmotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we
More informationINFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
More informationPatient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
More informationMargie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
More informationCANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR P: (541) F: (541)
CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR 97417 P: (541)517-9869 F: (541)543-2220 PATIENT INFORMATION Name: Age: DOB: Sex : Address: City: Zip: Home Phone: Cell
More informationName: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: M F Age: Birth date: Height: Weight: Occupation: Hobby:
Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Sex: M F Age: Birth date: Height: Weight: Marital Status: Single Married Widowed Separated Divorced Occupation: Hobby:
More informationNew Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered
More informationChiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
More informationAlivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
More informationAddress: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
More informationAverage Daily Diet: Morning Afternoon Evening
Average Daily Diet: Morning Afternoon Evening Habits: Cigarettes Coffee Tea Cola Alcohol Drugs Sugar Salt Other Family Medical History: Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizure
More informationExtended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
More informationOriental Medicine Questionnaire
Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you
More information15901 Central Commerce Drive, Suite 102 Pflugerville, Texas (512)
15901 Central Commerce Drive, Suite 102 Pflugerville, Texas 78660 (512) 494-4050 PATIENT INFORMATION Full Name (Print): Sex: M / F Date of Birth: (MM/DD/YY) / / Age: Street Address: City: State: Zip Code:
More informationAn Hao Natural Health Care Clinic 2348 NW Lovejoy St. Portland, OR
Edythe Vickers, N.D., L.Ac. Loren Lubin (Resident) Rachel Eppinga, N.D., L.Ac. Heather Krebsbach, N.D., L.Ac. Angela Read, L.Ac. Patient Intake Form Page 1 An Hao Natural Health Care Clinic 2348 NW Lovejoy
More informationIntegrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
More informationKEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
More informationHistory of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
More information~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
More informationDr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
More informationMEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
More informationCHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
More informationWelcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
More informationPATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
More informationPatient Name: Male or Female DOB: Patient Address: City/State/Zip: Patient Phone Number: Primary Policy holder: Relationship: DOB:
Fax to: 972-393-4200 Email to: denise@points4health.com Points of Health & Herbal Medicine Denise Edmiston, L.Ac., LCSW 413 W. Bethel Rd., Suite 202 Coppell, Texas 75019 P-(972)506-8113 F(972)393-4200
More informationChiropractic Patient Admittance Form
Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
More informationPatient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
More informationAllan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:
More informationHamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
More informationNew Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
More informationSOUTHSIDE COMMUNITY ACUPUNCTURE, LLC. Financial Policies
Disclosure of Information - Please Read the Following Carefully How to Prepare for Your First Visit : Plan on showing up a 15 minutes early to your first appointment and please wear, or bring with you
More informationWei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to
More informationHealth History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
More informationPEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
More informationSound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
More informationNEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
More informationNew Adult Intake Form
New Adult Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Today s Date: Age: Date of Birth
More informationStreet Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **
Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer
More informationMICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P.
MICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P. Certified by the American Board of Plastic Surgery Facial Aesthetic-Cosmetic-Craniofacial Surgeon-Reconstructive-Pediatric Plastic Surgery Reason for Consultation
More informationNEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
More informationBridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
More informationPatient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
More informationPlease fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
More informationGood Point Acupuncture Patient Health History
Good Point Acupuncture Patient Health History Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and
More informationJohn Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
More informationPATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
More informationCamas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
More informationACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:
Name: Date of Birth: Date: Address: Postal Code: Occupation: Telephone: Day: Cell Phone: E-mail address: Emergency Contact: Evening: Telephone: Male Female Where did you hear about Acupuncture for Health?
More informationNew Patient Demographics and Health History
New Patient Demographics and Health History Name: (first) (middle) (last) Date: / / Mailing Address: Apt/Unit: City: State: Zip: Home Phone: Cell Phone: Date of Birth: / / Email: May we email you treatment-related
More informationMEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
More informationPeterson Physical Therapy
Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell
More informationInterventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
More informationPATIENT INTAKE SHEET 2016
PATIENT INTAKE SHEET 2016 Patient Name: Last First Middle D.O.B.: Sex: M F Year Month Day Address: Street Address City May we leave a detailed message? Postal Code Phone : Residence Yes [ ] No [ ] Work
More informationAcupuncture Intake Form
Acupuncture Intake Form Name Age Birth Address City Postal Code Phone (home) (cell) OK to leave a message? Y/N Email address Occupation Employer Marital Status: Single / Married / Com Law / Divorced /
More informationNew Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
More informationHealth History Questionnaire
Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Email: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single
More informationCONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
More informationPersonal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
More informationThank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
More informationMy Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
More informationName: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
More informationCaspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
More informationDr. Stephanie Liebrecht, BSc., ND Phone: Saskatoon Wellness Centre Fax: Lorne Ave., Saskatoon, SK S7H 1Y4
Dr. Stephanie Liebrecht, BSc., ND Phone: 306-955-2633 Saskatoon Wellness Centre Fax: 306-955-2638 1814 Lorne Ave., Saskatoon, SK S7H 1Y4 Name Date of Birth / / Age (dd/mm/yy) Sex Marital Status Saskatchewan
More informationMetro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA
Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA 30328 404 255-8388 www.metroacupuncture.com Patient Information Last Name: First Name: Middle Initial: Street Address: City: State: Zip: Preferred
More informationCity State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
More informationUROLOGY CENTER OF PALM BEACH, P.A.
UROLOGY CENTER OF PALM BEACH, P.A. Name Date Date of Birth Age Sex (circle one) M F Social Security # Marital Status (circle one) Married Divorced Single Widowed Separated Home Address City Zip Home Phone
More informationApplication For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at
More informationNaturopathic Medicine Intake Form Adults (16+)
Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number:
More information