Sample redesign by WebologyWORX · Concept for Jing Japanese Acupuncture, not the official website
Please complete this before your first visit so your 90-minute appointment can focus on you. Everything you share is kept confidential.
Check any illness or disorder that has occurred in your immediate family (parents, siblings, grandparents).
Describe the complaint: location, date and/or time of onset, cause (if known), frequency, factors that make it worse and factors that relieve it.
Check any of the following that presently apply to you. Leave blank if it does not apply.
Do you crave particular foods?
Is the pain:
About your periods (if you no longer have periods, indicate what they were like before they stopped):
Do you suffer from premenstrual syndrome (PMS)?
During your mother's pregnancy, did she:
Indicate past or present use of the following.
The first office visit is 1.5 hours in length; please complete this form before the visit to allow time for reviewing your history, addressing your concerns and performing an acupuncture treatment. Return visits are generally 1 hour.
If you need to cancel, please give 24 hours' notice. If less notice is given, or an appointment is missed, the full fee will be billed to you.
Payment is due at the time of the visit. Upon request, an invoice with procedure and diagnosis codes can be printed for submitting to your insurance company or cafeteria plan. Prepayment is allowed as a convenience. If acupuncture is covered by your insurance, a superbill will be provided for you to submit for reimbursement; claims are not submitted to insurance companies as a service.
This disclosure complies with the State of Colorado, Department of Regulatory Agencies, Senate Bill 92-6. All rules and regulations set forth by the Department of Health are strictly followed, including proper cleaning and sterilization of equipment and office. The Department of Regulatory Agencies regulates the practice of acupuncture; complaints may be directed to the Director of the Division of Registrations, Department of Regulatory Agencies, 1560 Broadway, Suite 1340, Denver, CO 80202-5140, telephone 303-894-7851. Patients are entitled to receive information about the methods of therapy, techniques used and the duration of therapy, if known. Patients may seek a second opinion and may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations.
Patti L. Polman, Dipl. Ac. (NCCAOM) · Read Health Information and Your Privacy
