New Patients, Please complete the following online form before your first visit.

Name *
Name
Type of Service You seek: *
Check all that apply.
Have you received acupuncture before? *
Are you pregnant or currently trying to become pregnant? *
Do you have a bleeding disorder, take blood thinner medications or bruise easily? *
Do you faint often or easily? *
Do you have any allergies to metals? *
Do you have a pacemaker or other electrical implant? *
I CONFIRM THAT I UNDERSTAND THE FOLLOWING: Acupuncture is a form of therapy in which fine needles are inserted into specific parts of the body. Acupuncture is generally very safe. Serious side effects are very rare-less than 1 per 10,000. You need to be aware that: • Drowsiness occurs after treatment in a small number of patients and if affected, you are advised not to drive. • Minor bleeding or bruising occurs after Acupuncture in about 3% of treatments. • Pain during treatment occurs in about 1% of treatments. • Existing symptoms can get worse after treatment (less than 3% of patients). You should tell your Acupuncturist about this, but it is usually a good sign. • Fainting can occasionally occur in certain patients, particularly at the first treatment. • Single-use, disposable needles are always used in this clinic. *
I CONFIRM THAT I UNDERSTAND THE FOLLOWING: Acupuncture is a form of therapy in which fine needles are inserted into specific parts of the body. Acupuncture is generally very safe. Serious side effects are very rare-less than 1 per 10,000. You need to be aware that: • Drowsiness occurs after treatment in a small number of patients and if affected, you are advised not to drive. • Minor bleeding or bruising occurs after Acupuncture in about 3% of treatments. • Pain during treatment occurs in about 1% of treatments. • Existing symptoms can get worse after treatment (less than 3% of patients). You should tell your Acupuncturist about this, but it is usually a good sign. • Fainting can occasionally occur in certain patients, particularly at the first treatment. • Single-use, disposable needles are always used in this clinic.
Date *
Date