New Patient Intake Form

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Step 1 of 6

NOTE: Many factors must be considered in designing a complete health building program. Treating the whole person requires attention to all symptoms and conditions. Often minor symptoms are clues to delicate biochemical or somatic imbalances. Therefore, please complete all of this questionnaire as carefully and as completely as you can. This is a confidential record of your medical history and will be kept in this office. Information contained in this form will not be released to any person except when you have authorized us to do so.
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Address*
Birthday Date*
Are you Employed?*

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Do you have insurance that covers Acupuncture?*