NEW PATIENT FORMS

Please print, carefully read, fully complete, and sign the following three documents before coming to your first scheduled appointment.

Any questions can be discussed during the interview process before your treatment begins.

You may attach a copy of your medical records and/or medication list
to the Health History form rather than complete those sections if it is easier for you.

Please note that if your paperwork has not been completed or you forget to bring it
to your scheduled appointment; you may be asked to reschedule and you will not be treated. 

You will also be charged a $30, non-refundable fee. 

IT'S SO GREAT THAT YOU'RE TAKING CARE OF YOURSELF, EXPLORING ALL OF YOUR HEALTHCARE OPTIONS,

& PUTTING YOUR BODY IN GOOD HANDS.

RELEASE. RELAX. UNWIND. REVIVE. HAPPINESS & HEALTH AWAITS YOU!

Lower Level 2900 College Dr., Rice Lake, WI 54868 | 612.470.7999 | blackbirdacupuncture@gmail.com | @blackbirdacupuncture

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