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1201 Noe Street, San Francisco, CA 94114
415.285.0931
Acupuncture Clinic
San Francisco
Herbal
Formulas
Chinese Medicine
& Acupuncture
Pioneers
Harriet and Efrem
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Services and Intention
Chinese Medicine Works
provides acupuncture and herbal remedies, along with counseling in nutrition and self-care, in a friendly environment. We expect to assist your body and you in a healing process. Welcome.
We Request
Please spend the time to fill out the Patient Information and Self-Assessment Health Profile forms. We know you are busy, but this information will assist us in serving you.
Fees and Schedule
The first appointment costs $250. Follow-up visits are $150 and last about 1 hour. Fees may be paid with cash, check, debit or credit card. We make every attempt to begin treatments on time and hope that you will too. Please leave sufficient time for travel and parking.
Cancellation Policy
We have reserved time and space just for you. If you wish to cancel your appointment, we require at least 48 business hours advance notification, or by 5:00 PM on Thursday for a Monday appointment. Late cancellations or missed appointments will be billed in full to your account.
Let Us Know
We want to know how to best meet your needs. Please inform us of any special considerations. We look forward to your visit and will do our best to be of service.
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Efrem Korngold
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Birth Date
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Month
Day
Year
Your Age
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Birth Place
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Referred by:
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Relationship Status:
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Single
Domestic Partner
Married
Divorced
Widowed
Other
Number of Children
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Child's/Children's Ages (separated by comma)
Occupation
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Primary Provider or Physician
Prior acupuncture treatment?
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Yes
No
If yes, for what reason?
Describe complaints and concerns
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Health & Family History (childhood to present, including illness, injury, surgery, medications)
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Aches and pains
Indigestion
gas
bloating
reflux
constipation
diarrhea
other
Environmental Stressors
hot
cold
humid
dry
windy
pressure change
Chronic Infections
Candida
Herpes
EBV
HPV
HCV
HIV
Other
Allergies
dust
pollen
mold
cats/dog
wheat
dairy
peanuts
soy
other
medications
Specify "other"
Specify medication allergies
List medications, vitamins, supplements, including dosage
Typical Diet (cooked/raw)
Breakfast: Lunch: Dinner: Snacks: Beverages (cold/hot):
Women
PMS
irregular cycle
peri-menopausal
menopausal
hot flashes
infertility
abnormal pap
other
Description of "other"
Number of pregnancies
Number of miscarriages
Number of abortions
Men
prostate problems
urinary disorders
erectile dysfunction
infertility
other
Description of "other"
I understand that appointments not cancelled at least 48 business hours in advance, or by 5 PM on Thursday for a Monday appointment, will be billed to my account.
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