Patient Information


In order to help you save time, please download and complete these forms before your first visit.

Patient Medical History


Receipt of Notice of Privacy Practices

Financial Agreement

Pain Index

Referral for Acupuncture

**Only for Auto Accidents/Workman's Comp**

Preparing for Your First Visit

Please be prepared to stay for at least an hour. Make sure that you have eaten some form of protein at least a half-hour before.

As part of our diagnosis we ask to look at your tongue. It is believed, in Traditional Chinese Medicine (TCM), that the condition of your tongue can give information about your health. Thus, the day of your initial treatment, please do not brush your tongue.

Patient Privacy

We are required to maintain the privacy of your health information as required by law.  The health record and billing records we maintain are the physical property of this office.  The information in it, however, belongs to you. If you consent, we are permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations.  Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, diagnosis, treatment, and applying for future care or treatment.  It also includes billing documents for those services.

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