Acupuncture Intake - Patient Information Form printable pdf download

Acupuncture Intake - Patient Information Form

Acupuncture Intake

Kwan-Yin Healing Arts Center

2330 NW Flanders, Suite 101

Portland, OR 97210

(503) 701-8766

Thank you for scheduling with us, we strive to provide the best

possible integrative care for our clients. Here at the clinic we

have a team of Naturopathic Doctors, Oriental Medical

Practitioners, Licensed Acupuncturists, Body Workers, Massage Therapists,

Psychologists, Medical Doctors, Physical Therapists and Chiropractic Physicians.

During your initial evaluation your practitioner will do their best to do a thorough

evaluation and give you a treatment plan. You can assist us in that by making sure you

have fully completed the intake paperwork enclosed. The advantage of the integrative

office is that there are many modalities that can provide input should any of us find the

need for assistance.

We are located just west of the intersection of NW 23

on NW Flanders (between 23

Ave.). Parking is available in the main and lower lot; please do not park below the

building in the covered area. Wheelchair access for the first floor is located through the

main level parking lot. Please come a few minutes early and enjoy a cup of tea before

your appointment.

Please be aware that we ask patients to give us 24 hour notice if they need to reschedule

or cancel an appointment. Late cancellation or missed appointments incur a $45.00 fee or

greater, as we are unable to reschedule the appointment with another patient without

sufficient notice.

It will be a pleasure to support you on your path towards wellness.

PATIENT NAME:_____________________________________________________

PATIENT DOB:____________________________

KWAN-YIN HEALING ARTS CENTER

2330 NW FLANDERS ST. SUITE 101

PORTLAND, OR 97210

PH: 503.701.8766

FAX: 503.241.5484

Acupuncture Intake - Patient Information Form