Edgewater Acupuncture New Patient Intake
Email *
Date
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Patient Name (& Parent/Guardian if under 18)
Address - Street, City, State & Zip Code
Date Of Birth
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Age
Job
Cell #
Emergency Name / Phone Number
Primary Doctor Name / Phone Number
Current Medications (Include over the counter, supplements, vitamins & herbs)
How Did You Find Us?
I Acknowledge: Payment is due at time of service. No-shows and cancellations with less than 24 hours notice will be charged $25 for treatments, $40 for new patient intakes. *
What are your health goals? And why is this important to you?
For what problems are you currently seeking treatment? Rate the severity of each on a scale of 1-10, 1 = not bad at all, 10= the worst imaginable
What impact are your symptoms currently having on your life? What are they preventing you from doing? Why is this important to you?
What methods have you tried in the past to remedy these problems and how did these work for you?
What roadblocks or challenges are stopping you from getting where you want to go? Put a *** on the biggest one.
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