6. New Patient Visit Intake Form

iowa acupuncture clinic

8230 Hickman Road, suite B

Clive, Iowa 50325

Cell/text 515-331-8948

Patient Last Name *

Patient First Name, Middle Initial *

DATE of upcoming visit *

Date

Patient Birthday *

This is important for identification

Patient phone: *

mobile/cell is preferred

Patient email

Current Health Issues

Please answer the following questions form to list and describe any current health issues.

Be as specific as you wish.

Make sure to list refills of Herbal or Health products.

We will print this form with the Reverse Side as your SUPERBILL receipt. Please ask for a diagnosis code if you plan on filing with your Insurance Company

Please ensure you complete all the fields marked with an asterisk *.

All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you do not wish to disclose other than the fields marked with an asterisk *.

Main Health issues you want addressed

How have issues changed since last visit?

Are conditions worsened by work or life environment? Please Explain.

Have you had any medical testing since last visit? For what condition and what were the results?

Any new or changed medications/supplements?

Any changes to your exercise or relaxation activites?

What services of the Iowa Acupuncture Clinic are you interested in for this visit: *

Acupuncture Herbal Medicine (list in next section) Health Products (list in next section) Lifestyle / Diet Education

Pre-order Herbal medicine refills or any clinic health products to pick up at your visit. Enter each item in a blank below. You will not be charged until you check out for your visit. Don't worry about spelling... we know...

Product #1

Product #2

Product #3

Product #4

Upload any Documents you want to submit to the Clinic, such as lab reports, photos, diagrams.

Browse Files

If you would like to pause and continue later, choose CONTINUE LATER button below.

Otherwise, choose SEND FORM button to make sure we receive your daily intake form before your appointment on: {dateOf}

You will be able to give us any changes or additional information at the time of your visit.

If you have any questions or concerns, please contact our clinic at:

cell/text: 515-331-8948

Make sure to look for your reminder text and/or emails.

See you soon,

iowa acupuncture clinic

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