New Patient Are you looking for the insurance form? Click Here. Name*Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationDate of Birth MM DD YYYY Place of BirthTime of BirthReferred ByEmergency ContactPrimary Care Physician:Emergency Contact Phone NumberCan We Contact Your Physician?YesNoPlease Provide Your Current State of Health. Please Describe Your Personal and Family Health History. What Brings You to Acupuncture at This Time?How do You Hope to See Acupuncture Effect Change in Your Life?Acknowledgements* I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice. I acknowledge that I have been advised to consult a physician regarding my health concerns. I acknowledge and agree to the fees and insurance coverage policies of this practice. I acknowledge and agree to the nature of treatment of this practice I acknowledge and agree to the purpose of treatment of this practice I understand that Chinese medicine procedures have been shown to be safe and effective. I acknowledge and agree to the missed appointment/late cancellation policy of this practice. I authorize the insurance company to make payment to this practitioner for my treatments and services. I authorize the release of information concerning my (or my child’s) healthcare advice and treatment provided only for the purpose of evaluating and administering claims for insurance benefit. Please make sure all acknowledgements have been made before proceeding.Missed Appointements or Late Cancellations* I acknowledge and agree to the missed appointment/late cancellation policy of this practice. The fee for a missed appointment or cancellation with less than 48 hours notice is $150.