Forms

If you're coming in for the first time, please print out the following forms and have them filled out before your appointment. Your practitioner will go through all of them with you as well, so don't worry if you don't understand something or have any questions. 

 

If you don't have access to a printer, please read through the forms to have an idea of what's on them and then arrive 20 minutes earlier than your scheduled appointment time in order to fill them out. 

Download
Acupuncture Intake
In this form you'll share your contact information, medical history, and current health conditions (4 pages)
Acupuncture Intake.docx
Microsoft Word Document 43.1 KB
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Evaluation by Physician
Licensed Acupuncturists are not considered primary care practitioners in the state of Texas, which means that someone else - such as a physician or chiropractor - must also have seen you and know about your condition. In this form you'll verify that you have been evaluated by someone else or are coming in to relieve chronic pain, to quit smoking or another addiction, or to lose weight, all of which are exempt from this rule (1 page)
Evaluation by Physician.docx
Microsoft Word Document 13.4 KB
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Acupuncture Consent and HIPAA
In this form you'll give your consent to receive treatment and acknowledge that you've read our privacy practices, which you can find below (1 page)
Acupuncture Consent and HIPAA.doc
Microsoft Word Document 26.0 KB
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Privacy Practices (Do Not Have to Print)
Please read through these practices before signing the previous document. You may print these for your records if you choose, but it's not necessary to bring them with you to the clinic (2 pages)
Privacy Practices.docx
Microsoft Word Document 16.7 KB