Clinic Forms

Instructions For Your First Appointment

1. Call our office at 239-260-4566 to schedule your appointment.
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 electronically submit the claims 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 at time of service.
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 $50 for acupuncture or $110 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.

New Member Forms: one section only

Non-Insurance Acupuncture Intake Forms:

If you do NOT have acupuncture insurance beneifts and are preparing your first acupuncture treatment, please only fill out the following two forms in this section:

1. 1. New Member Health Intake Form
   2. New Member Application and Waiver Forms

Insurance Acupuncture Intake Forms:

If you do have acupuncture insurance benefits and are preparing your first acupuncture treatment, please only fill out the forms in this section.  Please visit the insurance page for important information regarding our insurance policy.

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

Pediatric Forms (Ages 0-8 ONLY):

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.

Please only fill out the following three forms in this section for your child’s visit (0-8yrs old):

1. 1. Pediatric Patient Intake Form
   2. Signs and Symptoms Checklist
   3. Consent Forms – This form must be printed in color and two signatures are required.

Functional Medicine New member Forms:

If you are preparing your first functional medicine visit, please only fill out the following four forms.  These forms are only for those members that are not receiving acupuncture services.

1. 1. New Member Application and Waiver
   2. New Member Health History Intake
   3. Adrenal Stress Profile Questionnaire
   4. Health Appraisal Questionnaire