Downtown New Patient Acupuncture Forms

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Oaktree New Patient Acupuncture Forms

Patient Information

Patient Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Date of Birth*

Email Address*

Cell Phone*

Home Phone

Work Phone

Medical Doctor Name

Workplace / Occupation

Marital Status

Single Married Divorced Widowed Common Law Separated

Referral:*

How did you hear about Oaktree?

I consent to receiving email communication from Oaktree *

Yes No

(Emails we will send you include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email)

Acupuncture History

Have you ever been to an acupuncturist before?*

Yes No

Name of Acupuncturist and City

Approximate date of last visit:

Duration and frequency of care:

[Example: A couple times, Twice a week for 6 months, Weekly for 3 years]

Major Health Complaints

1)*

2)*

Medical History

Do you take any supplements? Which ones?

Example: Omega 3, Vitamin B, Probiotics, Vitamin D, Multivitamin, Iron

Medications - Name and for which condition(s)

Family Health History - What significant health concerns have your family members experienced?*

Surgeries - Please list and for what condition(s) (include year performed)*

Other health problems, concerns, or additional information: