New Patient Form

First Name

Last Name

Date of Birth

Preferred Pronouns

Example: He/She/They

Street Address

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Phone Number

Email Address

What is the best way to contact you?

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

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Emergency Contact

Phone Number

Relationship to you

Have you received acupuncture before?

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If so, where?

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?

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.

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Contact Information

Focus Of Treatment

Health History

Clinic Policies