New Patient Health History Questionnaire

Name *
Address *
Date of Birth
Date of Birth
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
Checkbox My approved methods of communication regarding my medical information are indicated below13 *
Breakfast? Lunch? Dinner? Drinks (soda, alcohol, coffee)? How many drinks a day?:
Please check all that apply in the follow sections.
Medical History
Family Medical History
Skin & Hair
Reproductive & Gynecologic
I have read and agree to the Acupunture Informed Consent to Treat terms *
I hereby request and consent to the performance treatments and other procedures within the scope of the practice of acupuncture on me (or the patient named below, for whom I am legally responsible) by the acupuncturist named below and/or other licensed acupuncturist who know or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese Massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect to cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known in my best interest. I understand that the results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
I have read and agree to the Financial Agreement terms. *
Cancellation policy We require 24 hour notice if you are unable to keep your appointment to allow time to offer your appointment to another patient. If a 24 hour notice is not given, you will be charged a missed appointment fee ($60). Insurance We are out of network with all insurance companies. Upon your request, we will call to verify acupuncture benefits and your deductible amounts. You are responsible for payment at the time of service. Most insurance companies that cover out of network acupuncture services will reimburse you for a portion of what they deem reasonable and customary, after the deductible has been met. Please let us know if you would like us to bill insurance for your visit. Please remember that your insurance policy is a contract between you and your insurance company, and that our office is not a party to that contract. Should your insurance carrier request additional information, we will gladly submit the paperwork to them to aid in the processing of your claims; however, you are ultimately responsible for the charges incurred at our office. I have read and understand the Magnolia Wellness Financial Agreement. I understand that all services that I have are my financial responsibility.