Please submit intake form below before your scheduled appointment time.

Print & complete HIPAA and Colorado Mandatory Disclosure Notice form and bring with your to your appointment. Time will not be added to appointment time if forms are not complete upon arrival. I appreciate your understanding.

This is a confidential questionnaire to help me determine the best treatment plan for you.

Name:*
Today's Date*
Date Format: MM slash DD slash YYYY
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Emergency Contact Name:*
Emergency Contact Phone Number
Primary reason for today's acupuncture visit, describe briefly:
What treatments have you had for this condition?
What treatments have you had for this condition?
Check any of the conditions below that are in your health history:
Other, and any other helpful info.
Have you had any major accidents or traumatic injury (Physical or Emotional?
Describe briefly
Please list any surgeries and their dates
List any major medical conditions that exist in your family (parents and siblings)