General Acupuncture Intake Form

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 Country
How did you hear about us?*
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

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.
Email
This field is for validation purposes and should be left unchanged.

CALL (778) 228-4275

Health history form for acupuncture and cupping therapy

Step 1 of 3

Your Health

Risk of Treatment

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