Acupuncture Intake Form

Please fill out this form to the best of your ability and comfort level
1. Personal Information *
2. Emergency Contact: *
3. Emergency Contact Phone: *
4. Primary Physician Information
5. Have you had Acupuncture before? *
6. Please list any Medications you are currently taking, including prescriptions, supplements, or over the counter
7. Please list any recent Surgeries or Medical treatments you have received
8. Are you pregnant or nursing?
9. What do you hope to achieve during your visit?
10. Do you suffer from chronic pain?
11. If yes, please explain:
12. What makes it better?
13. What makes it worse?
14. Please indicate any of the following that apply to you:
15. Explain any conditions you have marked above:
16. Are there any other conditions that are not listed above?
17. Please list any allergies or sensitivities you have
18. Is there anything else you would like to say about your health?

The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information. All patient information is handled under the HIPPA Privacy Act - Confidential HIPPA approved form. Your signature acknowledges that you understand.

I hereby request and consent to the performance of the following diagnostic techniques and treatment modalities of oriental medicine on me (or the patient named below, for whom I am legally responsible) by any licensed doctor of Oriental Medicine credentialed by Gambei: acupuncture and other oriental medicine procedures; pulse evaluation; manual palpation on a variety of areas of my body; muscle, orthopedic and neurological testing; modes of physical therapy such as massage, heat/cold therapy, electrical and/or magnetic stimulation; the prescription of herbal and homeopathic medicines, as well as dietary supplements, exercise regiments and lifestyle counseling.I have had the opportunity to discuss with a doctor of Oriental Medicine the nature and purpose of acupuncture, including the procedures and treatment protocols associated with oriental medicine. I understand that, although acupuncture and other medical procedures have helped millions of people, no guarantee of cure or improvement in my condition is given or implied.I understand and am informed that, as in the practice of conventional medicine, in the practice of Oriental Medicine there are some risks of treatment. I understand that while unlikely, possible risks include, but are not limited to: bleeding, bruising, pain or other strong sensations at the location of needle insertion, nerve pain, aggravation of current symptoms, appearance of new symptoms, puncture of organs, and burns. I do not expect the doctor to be able to anticipate and explain all risks and complications, and during course of treatment I wish to rely on the doctor's judgment, based on the facts then known.I have read or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above named procedures. I intend for this consent form to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment. 
By signing below, I agree with all of the information above, and I have filled out this form to the best of my ability. *