New Patient Form

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.

Select Provider*

Name*

First Last

Today's Date*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

use Home Phone for appointment messages

Mobile Phone

use Mobile Phone for appointment messages

Email

Birth Date*

Your Age*

Birth Place*

Referred by:*

Relationship Status:*

Number of Children*

Child's/Children's Ages (separated by comma)

Occupation*

Primary Provider or Physician

Prior acupuncture treatment?*

Yes
No

If yes, for what reason?

Describe complaints and concerns*

Health & Family History (childhood to present, including illness, injury, surgery, medications)*

Aches and pains

Indigestion

Environmental Stressors

Chronic Infections

Allergies

Specify "other"

Specify medication allergies

List medications, vitamins, supplements, including dosage

Typical Diet (cooked/raw)

Women

Description of "other"

Number of pregnancies

Number of miscarriages

Number of abortions

Men

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.

By typing your name below, you digitally sign this form*

First Last

Services and Intention

Pages

Contact

New Patient Form

Services and Intention

Pages

Contact

Subscribe to our newsletter