New Patient Forms

 

Getting Started
To get started you will need to fill out a series of health history and consent forms. The information you provide will assist your practitioner in formulating a complete health profile. Please take the time to fill out all the necessary forms as completely as possible and bring them to your first office visit. If you have any questions, please make a list and bring it to your first appointment. All information is confidential.

Check List

  • Download the appropriate forms depending on whether you are a Fertility patient or a Non-Fertility patient.
  • Please double check that you have downloaded all of the pages for each form.
  • Be sure each copy is legible. You may re-copy forms on high-quality paper if needed, as these documents will become part of your permanent medical file.
  • If for some reason you cannot download the necessary forms, please contact the office and we will be happy to mail them to you. In the event that you do not receive the forms before your scheduled appointment, please arrive 20 minutes early to fill out these forms so as not to waste valuable treatment time.

 


All documents are PDF format, click each to download.

 

 

Fertility Patients
(Patients who are pursuing treatment for the express purpose of fertility enhancement)

  1. Office Policy Signature Form (2pgs.)
  2. Health History Form (4pgs.)
  3. Fertility Treatment History Form (3pgs.)
  4. Fertility Consent Signature Form (1pg.)
  5. Acupuncture Consent Form (1pg.)
  6. Notice of Privacy Practices (HIPPA) (2pgs.)
  7. HIPPA Consent Signature Form (1pg.)
  8. Release of Health Records Signature Form (1pg.) ** Optional

Non-Fertility Patient
(Patients who are pursuing treatment for any other condition other than fertility)

  1. Office Policy Signature Form (2pgs.)
  2. Health History Form (4pgs.)
  3. Acupuncture Consent Form (1pg.)
  4. Notice of Privacy Practices (HIPPA) (2pgs.)
  5. HIPPA Consent Signature Form (1pg.)
  6. Release of Health Records Signature Form (1pg.) ** Optional