Edgewater Acupuncture New Patient Intake
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Email *
Patient Name (& Parent/Guardian if under 18)
Address - Street, City, State & Zip Code
Date Of Birth
MM
/
DD
/
YYYY
Cell #
Emergency 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 $35 for treatments, $40 for new patient intakes. *
Print Name and Date
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