Chicago Acupunture Intake form
New Patients: Please fill out the following consultation form, and send it to us, prior to your first appointment so that we can better service your needs. If you have a question fill out the short form here, or give us a call at (312) 399-4919, or use direct e-mail:

Please, make sure to fill out all required fields marked with * After you press submit, if you missed a required field, the form will not submit, but it will mark in red the missing fields to remind you to fill them in. Please do so, and press send again.
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Email *
Date05/15/19 *
Mobile Number *
First Name *
Last Name *
Work Phone
Home Phone
Age *
Gender *
Home Address
City *
State *
Zip *
How many times per year do you get a cold or the flu? *
Summarize how you eat; List any special diet such as high protein, food, etc.
Family Medical history
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