You only need to fill this one out if you want us to verify your acupuncture coverage. We are in-network with Cigna’s PPO plan and with Valley HealthPlan’s Commercial program
Just for patients being seen for fertility concerns.
To be filled out when looking for treatment for female hormonal-type issues
Health Insurance Portability and Accountability Act of 1996.
General Patient information, location, emergency contact.
Short survey of how you found us, your goal for acupuncture., etc.
Overall issue; family history, medications taken.
Specific information on pain issues.
Our policies on rescheduling and cancelling appointments.
Agreement to arbitrate before suing should a disagreement occur, and Informed consent to accept treatment.