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Alexis Arvidson Acupuncture | New Patient
5
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New Patient
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Click Here.
Name
*
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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Nevada
New Hampshire
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New Mexico
New York
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Ohio
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Oregon
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Occupation
*
Date of Birth
*
MM
DD
YYYY
Place of Birth
Time of Birth
Referred By
*
Emergency Contact
*
Primary Care Physician:
*
Emergency Contact Phone Number
*
May we contact your physician?
*
Yes
No
Please provide your current state of health.
*
Please describe your personal and family health history.
*
What brings you to acupuncture at this time?
*
What is the quality of your sleep?
*
What time do you go to sleep and wake up each day?
*
Do you wake to use the bathroom during the night?
*
Yes
No
How do you feel when you wake up?
*
How is your appetite?
*
Please list the foods you commonly eat and the times you take each meal.
*
(Please include, Breakfast, Lunch, Dinner, Snacks & Drinks)
What is your daily water intake?
*
How is your digestion?
*
Do you experience one or more bowel movements per day?
*
Do you experience gas, bloating, acid reflux or frequent burping?
*
Do you have chronic pain? Please describe.
*
How is your mood in general?
*
How would your friends and family describe you?
*
Do you feel your life has purpose?
*
Do you have meaningful relationships?
*
If you could change one thing in your life that would increase your vitality, what would it be?
(The next five questions are for Female clients exclusively)
How many days is your cycle?
Do you have PMS?
Do you have breast tenderness?
Do you experience blood clots when you bleed?
How long does your bleeding last?
Thank you for your time and your honesty. These reflections will help the success of our work together.
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 $170.
New Patient Registration