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Clinic Forms

Instructions For Your First Appointment


  1. Call our office at 239-260-4566 to schedule your appointment: please have your insurance card available if using insurance.
  2. Download and fill out the following paperwork prior to your appointment. You can save time by bringing the completed forms with you on your first visit. Download, print and completely fill out the PDF documents below. The consent and arbitration form needs to be printed in color. (Download free Adobe Reader software here.)
  3. If using insurance, confirm in advance of your appointment that you have coverage. As a courtesy our office will double-check your benefits for you but it is your responsibility to check your coverage in order to avoid a denial of your claim. Deductibles and copays will apply.
  4. Check in at the front desk 15 minutes prior to your scheduled appointment. If you are unable to download and fill out the required paperwork listed above, you must arrive no less than 20 minutes prior to your appointment to fill them out. If you arrive less than 20 minutes before your appointment we will be unable to accommodate you as the forms are lengthy and we are unable to begin your consultation without completed paperwork.
  5. Acupuncture & Natural Health Solutions has a 24-hour cancellation policy: please make any cancellations within that time frame. New patients who cancel with less than 24 hours notice or who fail to attend an initial appointment will be charged a fee of $85 for acupuncture or $90 for massage if they wish to reschedule. This fee must be received by our office prior to rescheduling.
  6. Please wear loose fitting clothes that allow easy access to your arms and legs. Shorts and a tank top are the best, but loose pants that can easily be rolled above the knee will work as well.
  7. Eat a small snack within the two hours prior to your acupuncture visit.

Download Applicable Forms Below:
Please download, fill and print out applicable form(s) to speed up the intake process during your first visit.


Acupuncture Treatment Patient Forms:

If you are preparing your First Acupuncture Treatment visit, please only fill out the following 2 Forms:

    1. New Patient Health History Intake Form
    2. Consent Forms


    Pediatric Patient Forms:

    If you are preparing for Your Child’s First Acupuncture visit (for children ages 0 – 8 years old).

    1. Preparing For Your Child’s First Acupuncture Visit – Please read this form prior to your first visit. This form does not need to be printed.
    2. Please only fill out the following 3 Forms for your child’s visit:

    3.  Pediatric Patient Intake Form
    4. Signs and Symptoms Checklist
    5. Consent FormsThis form must be printed in color and two signatures are required.


    Functional Medicine Treatment Patient Forms:

     If you are preparing your First Functional Medicine visit, please only fill out the following 4 Forms:

    1.  New Patient Paperwork
    2. Adrenal Stress Profile Questionnaire
    3. Health Appraisal Questionnaire
    4. Consent Forms


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