Intake Form

Required Field
Personal Info
Contact Info
Emergency Contact
Other
Medical Info
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Conditions
Well Being
TMJ (Jaw)
LIV/GB (Wood)
HT/SI (Fire)
Oncology
Female Health
Area of Complaint
Headaches
Musculoskeletal
Cardiovascular
Blood
Skin
Neurological
Respiratory
Kidney
Gastrointestinal
Endocrine
Hearing
Immune
Miscellaneous
Prenatal (check boxes to enter details below)
Emotion / Mood
Review & Agree
  • If you need to cancel or move your appointment, we respectfully ask for 24 hours notice in order to avoid a cancellation fee.
  • We will advise you of this upon a first missed appointment, after a second missed appointment a payment method will be collected and 50% of the service will be charged.
  • All subsequent late cancellations/missed appointments will be charged at 100% of service(s) scheduled.