New Patient Form

Contact Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Preferred Pronouns

Example: He/She/They

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

What is the best way to contact you?

Phone

Text (SMS)

Can we add you to our email list for future news and announcements?

Yes

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Relationship To You(Required)

Have you received acupuncture before?

Yes

Where did you receive acupuncture?

How did you hear about Heil Health & Wellness?

Focus Of Treatment

What health concerns/goals brought you into the clinic?

What improves your condition?

What makes it worse?

How does this issue affect your daily life (e.g., in relation to sleep, work, emotions)?

What other forms of treatment have you sought for this issue? Results?

What tests have been done related to your health concern (e.g., blood work, MRI, EKG)? Results?

Health History

Please list all medications, herbs, vitamins, and supplements you currently take and their purpose:

Do you take a blood-thinning medication?

Yes

Do you have a pacemaker?

Yes

Please list any known allergies:

Please list any dietary restrictions:

What temperature do you prefer your beverages?

Hot

Room Temperature

Cold

Check any current or past health issues you have experienced:

What type of Cancer?

Have you had any major surgeries, accidents, injuries, or illnesses? Please describe:

Have any of the above left scars? If so, where?

How stressed do you feel on a regular basis?

What is the biggest contributor to your stress levels?

Clinic Policies

Services: Heil Health & Wellness provides patients with high-quality traditional Chinese medicine, including acupuncture, herbal therapy, cupping, gua sha, moxa, tui na, and dietary or lifestyle advice. Necessary treatments will be discussed before performing them.
Herbal therapy: Chinese herbs may be recommended and provided to patients at the time of their appointment. The price of herbs varies depending on the amount provided. Pricing of herbs can be discussed at the time that they are recommended.
Appointment arrival: Please arrive five minutes early so that you have time to settle into the space before your appointment. Late arrivals will be accommodated as possible, but may result in shortened or rescheduled treatments.
Cancellation policy: We request at least 24 hours of notice to reschedule or cancel an appointment. If notice is not received within 24 hours of your appointment, you will be charged in full for the appointment. Repeated late cancellations may result in same-day scheduling only.
Dress / coverings: Please wear comfortable, loose-fitting clothing to your appointment. Many people bring t-shirts and shorts to change into, especially during cold weather. Patients may be covered with a drape during treatment as necessary or upon request.
Non-discrimination: Heil Health & Wellness provides the above services in a non-judgmental, compassionate atmosphere that is open to all ages, races, genders, body types, physical abilities, economic backgrounds, sexual orientations, and religions.
Sexual harassment: The services provided by Heil Health & Wellness are therapeutic, not sexual, in nature. Sexual advances or requests of employees and/or patients will not be tolerated in our space. Even questionable sexual discussion can be cause for termination of services.
Intoxication: We respect all people's methods of self-medication, but request that patients refrain from ingesting alcohol or drugs before their appointments. Arriving in an intoxicated state impairs our ability to receive full consent from you and may result in rescheduling.
Privacy: We adhere to current HIPAA guidelines protecting the personal and health-related information we receive from you in both written and verbal form. Click here to review our privacy policies in full.

Insurance Policies

Insurance users agree to the following policies by signing below:

Verification of Benefits: As a courtesy, we will verify your insurance coverage as well as submit your claims. We suggest you also verify your benefits with your carrier as quoted benefits are not a guarantee of coverage.
Assignment of Benefits: You authorize direct payment of your medical benefits to Heil Health and Wellness, PLLC.
Release of Information: You authorize the release of any medical or other information necessary to process and pay your insurance claims.

Date

Contact Information

Focus Of Treatment

Health History

Clinic Policies

Insurance Policies

By signing below, you acknowledge that the above information has been filled out correctly and completely to the best of your knowledge.