New Acupuncture Patient Form

Patient Data

Patient Name(Required)

Birth Date(Required)

Gender(Required)

Male

Female

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Email(Required)

Referred By

Employer

Occupation

Medical History

What medications are you taking and for what conditions (Please list dosage and amounts, etc). If none, please type none.(Required)

If a family member has had any of the following, check all that apply

PLEASE READ AND SIGN IF YOU WISH TO BE TREATED WITH ACUPUNCTURE OR ACUPRESSURE.

I, the undersigned, fully understand that no therapeutic treatment, including these, can carry with it any stated or implied guarantee of success. I also understand that these treatments may produce some slight bruising and I release Mike Worley, L.Ac. from responsibility in the event that that should occur.

Signature

Date

Call to Make an Appointment (714) 626-0074

Patient Data

Mailing Address

Current Complaints

Past & Present Medical Issues

Medical History

PLEASE READ AND SIGN IF YOU WISH TO BE TREATED WITH ACUPUNCTURE OR ACUPRESSURE.

Lander Chiropractic