Patient Forms

We are COVID compliant and take the utmost care to protect your health.

Questions?

Privacy and Security

To maintain your privacy all information is collected and stored on our HIPAA-compliant servers. Please download our Tele-health Instructions Guide and HIPAA Privacy Policy for your appointment.

General Intake Form

Please complete your intake form prior to your first appointment. Please allocate a minimum of 20 minutes for the form, and additional time if you have a complex condition. It is recommended to use a desktop or laptop computer for a smoother interface.

Regardless of whether you are seeking treatment for a "simple" pain or a more complex issue, it is crucial to fill out the form attentively and thoroughly as Chinese medicine takes a holistic approach to all treatments.

**IMPORTANT NOTE: If you need to work on the intake form in stages, you will have to create a JotForm user account, verify your email and then log in to www.jotform.com to continue. You might be prompted to enter the password twice. Your form is saved on a HIPPA compliant part of the JotForm servers.

If you are seeking treatment for COVID-19 or long-hauler COVID symptoms, please fill out this form.

Insurance Verification Form

To check your coverage, please fill out our insurance verification form directly below and we’ll take care of the rest. Please allow 2-3 business days for results.

File Upload Form

Securely upload labs, radiology reports or medical records here.