contact us

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.

           

123 Street Avenue, City Town, 99999

(123) 555-6789

email@address.com

 

You can set your address, phone number, email and site description in the settings tab.
Link to read me page with more information.

Intake forms

Insurance Verification

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

 

Fertility Intake – Download Form

Just for patients being seen for fertility concerns.

 

Women Intake – Download Form

To be filled out when looking for treatment for female hormonal-type issues

 

HIPAA -  Download Form

Health Insurance Portability and Accountability Act of 1996.

 

Patient Info – Download Form

General Patient information, location, emergency contact.

 

New Patient Questionnaire – Download Form

Short survey of how you found us, your goal for acupuncture., etc.

 

Patient Intake – Download Form

Overall issue; family history, medications taken.

 

Pain Intake – Download Form

Specific information on pain issues.

 

Cancellation-Rescheduling Policy – Download Form

Our policies on rescheduling and cancelling appointments.

 

Arbitration/Consent to Treat – Download Form

Agreement to arbitrate before suing should a disagreement occur, and Informed consent to accept treatment.