• Image
  • iowa acupuncture clinic

    8230 Hickman Road, suite B

    Clive, Iowa 50325

    Cell/text 515-331-8948

  •  / /
    Pick a Date
  •  / /
    Pick a Date
  • 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 *.


  • 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...

  • Browse Files
    Cancelof
  • 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

  • Should be Empty: