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General Acupuncture Intake Form
Kathryn Sawers
2023-02-17T21:31:15+00:00
Health history form for acupuncture and cupping therapy
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General Acupuncture Intake Form
Date of birth
*
MM slash DD slash YYYY
Name
*
First
Last
Phone
*
Please provide us with the phone number for which you are most easily reached.
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How did you hear about us?
*
friend/family referral
Varnish
internet search
social media
media article
advertising
Referral
If you have been referred, please let us know by whom so we can thank them.
Gender
Female
Male
Non-Binary
Prefer not to specify
Have you had acupuncture before?
Yes
No
Occupation
Your Health
Please check off any current or past medical conditions that apply.
*
high blood pressure
low blood pressure
diabetes
cancer
cardiac problems
hepatitis
headaches
immune disorder
arthritis
respiratory disorders
skin diseases
none of the above
If you have any other health concerns we should be aware of, please specify.
List any medications, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.
Do you have any allergies?
*
Yes
No
If yes, please specify.
Do you any problems with bleeding or bruising?
Yes
No
For your condition, please let us know what methods/treatments you have tried.
*
Is there any additional information you would like to share with your practitioner?
Risk of Treatment
• Bleeding and/or bruising. You may have an increased risk if you have a bleeding disorder or if you're taking blood thinners. • Pregnancy. Some acupuncture points are thought to stimulate labor, which could result in a premature delivery.
Client Waiver
*
I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. By my signature below, I give consent for esthetic services rendered by Collective Skin Care and its affiliates.
I have been informed and advised of all risks associated with the services and procedures I will be receiving.
I consent to recieve acupuncture and cupping therapy treatment.
I agree to comply with the instructions provided by the practitioner.
I understand that I am responsible to find out the amount (limit) of my insurance coverage, and that I am responsible to cover all treatment fees and submit for reimbursement from my insurance provider according to my insurance agreement.
Consent
*
I hereby release Collective Skin Care, its affiliates and directors from liability for any injury, loss or damage that may result from any services provided or treatments rendered. This release binds my heirs, successors and assigns.
Cancellation policy and credit authorization release
*
We request 24 hours notice for cancellations or appointment changes. Cancellations within 24 hours of the scheduled service are subject to a charge equal to 100% of the booked appointment.
I understand the cancellation policy and agree to pay any cancellation fees I incur.
Name
This field is for validation purposes and should be left unchanged.
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