Acupuncture Assessment Form

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Acupuncture Assessment Form


PATIENT INTAKE FORM. ACUPUNCTURE ASSESSMENT. Important: This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you.


By signing this form, I confirm consent to treatment within the scope of Traditional Chinese Medicine (TCM) for me (or the patient named below, …

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Initial Intake Form. Today’s date _____/_____/______. Thank you for taking the time to complete the following information which will help me assess your …