New Patient Form
Common Good Community Acupuncture

Name*

Legal name

Last name*

Pronouns

Email*

Date of birth*

Emergency Contact

Have you had acupuncture before?*

Yes

No

Ear acupuncture only

List serious accidents, illnesses, and surgeries with dates

List all medications, herbs, and supplements you are taking

Do you have a pacemaker?*

No

Yes

Do you have a bleeding disorder?*

No

Yes

What are your primary reasons for seeking acupuncture?*

Mark for past or current conditions

Allergies

Asthma

AIDS or HIV

Anxiety

Cancer

Depression

Digestive issues

Diabetes

Epilepsy

Heart disease

Hepatitis

Insomnia

Low blood pressure

Long Covid

Pregnant or trying

Stroke

Tuberculosis

Informed Consent Acupuncture: I hereby request and consent to the performance of acupuncture treatments by the acupuncturists employed at Common Good Community Acupuncture and Incite Healing LLC, on myself or on the patient named below, for whom I am legally responsible. I understand that acupuncture is a generally safe method of treatment, but that it may occasionally have some side effects, including bruising, numbness, tingling or pain near the needling site that may last a few days, and in rare cases, dizziness or fainting. Although extremely rare, nerve damage has occurred in connection with acupuncture treatment. Infection is another possible risk, though this clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that the acupuncturists are not providing Western medical care, and that acupuncture is not a replacement for diagnostic medical procedures and treatments. Certain conditions may require evaluation and/or treatment by a Western physician. I have read, or have had read to me, and completely understand the risks and benefits of acupuncture treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Release of Liability for Lost or Stolen Goods: Common Good Community Acupuncture and Incite Healing LLC, is not responsible for lost or stolen goods. We cannot guarantee the safety of your valuables while you receive treatment. Do you understand and agree to our informed consent policy? (required)*

Yes

If you understand and agree to our informed consent policy please sign (type)*

Common Good Community Acupuncture makes every attempt to make acupuncture available to as many people as possible at the most affordable rates. • In respect for our intentions to offer high quality healthcare at affordable prices, we ask for 12-hours advance notice if it is necessary to cancel an appointment. • All appointments that are canceled with less than 12 hours advance notice, as well as appointments missed without notice, will incur a $25 charge. • If appointments have been purchased in a package, the missed or canceled appointment will be deducted from the number of remaining appointments in that package. Do you understand and agree with our financial policy?*

Yes

If you understand and agree with our financial policy please sign (type).*

Submit

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