Acupuncture Intake Form

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Basic Information

Please note, due to the differences in each patient's insurance plan we rely on you to know your coverage. You can visit our website at to verify your insurance!

Primary Complaint

Health History

Family History

Symptom List -- Select all that apply now or in past for you in each category below.

Hormonal Imbalances

Thank you for filling out our Acupuncture Intake Form! Once you have submitted it you should expect to hear from us within 5 business days. If you have any questions feel free to give us a call. We'll talk to you soon!

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