Acupuncture Intake Form
Dr. Lucy Liu
225 Broadway, Suite 2720, New York, NY, 10007
Tel: (212) 226-2425
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Email *
Patient Full Name (Last, First, M.I.) *
Date Of Birth *
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Address (Street, Apt, City, State, Zip Code) *
Phone Number - Cell *
Sex *
S.S.N *
Occupation *
Work Company *
Work Phone Number
Work Address (Street, Apt, City, State, Zip Code) *
Emergency Contact *
Emergency Contact Relationship *
Emergency Contact Phone Number *
Referred By *
Primary MD *
Primary MD Phone *
Current Weight *
Height *
Last Physical Exam Date *
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Any Major Medical Conditions and History, Select ALL that apply: *
Required
Medication List *
Vitamin and Other Therapy
Primary Presenting Problem *
Primary Presenting Problem Onset Date
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Primary Problem Pain Scale *
Secondary Presenting Problem
Secondary Presenting Problem Onset Date
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Secondary Presenting Problem Pain Scale
Clear selection
Additional Problem
Additional Problems Onset Date
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Additional Problem Pain Scale
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Social History - Select all that apply *
Required
Family Medical History - Mother's Side *
Family Medical History - Father's Side *
Family Medical History - Siblings *
If any of the above is deceased, what was the cause? *
Maritital Status *
Family Size *
Pregnant/Nursing *
Insurance Company *
Insurance I.D *
Insurance Address (Street, Apt, City, State, Zip Code)
Insurance Phone Number *
Insurer *
Insurance Consent:

I, hereby authorize Lucy Liu Acupuncture to bill my insurance company for services provided to me. I understand and agree to the following:


   1.    I authorize the release of any medical information necessary to process insurance claims and obtain payment for services rendered.

   2.    I authorize direct payment of medical benefits to Lucy Liu Acupuncture for services provided.

   3.    I understand that I am responsible for any charges not covered by my insurance, including co-payments, deductibles, and services deemed non-covered or out-of-network.

   4.    I agree to inform Lucy Liu Acupuncture of any changes to my insurance coverage or personal information promptly.

   5.     I understand that I am responsible for paying the office fee if my deductible balance hasn't been met by my appointment date. 

   6.    I acknowledge that this consent is valid for the duration of my treatment unless revoked in writing.



Acknowledgment and Signature:


By signing below, I confirm that I have read and understood this consent form and agree to the terms outlined above.


   •    Patient/Guardian Signature:

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Consent for Acupuncture: 

I, understand acupuncture treatment to involve the use of needles, acupressure, moxibustion and electrical stimulation etc. The risks, although limited, include: puncturing organs in the abdomen or chest cavities. Acupuncture may affect people on all levels: physical, emotional, mental and spiritual, because it works with the whole body to create balance. The duration of treatment varies from person to person depending on the specific illness and their constitution. I fully understand that there is no stated or implied guarantee of success or effectiveness after a specific treatment or series of treatments. By typing my name below I am agreeing to the above.
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Date of Consent for Acupuncture Agreement Signed *
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OFFICE POLICY  *
Cancellation fee and credit card storage

Please make sure to cancel 24 hours before your appointment to avoid being charged a cancellation fee of $110. This amount will be charged to the storage card on file. Your copayment will not be charged with the card on file and will not be charged for any services you do not authorize.

Lateness

Please be considerate of mine and other patients' time and come on time to your appointment. If you’re more than 15 minutes late you will be a walk in patient. You will have to wait for the next available room. I hope all my patients understand these new office rules which will help keep our schedule flowing with no conflict.
Office Policy Signature  *
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