Iowa Acupuncture Clinic Patient Information form

Patient Information
iowa acupuncture clinic

8230 Hickman Road, suite B

Clive, Iowa 50325

Cell/text 515-331-8948
Please complete the following information for your patient file. All of your patient file is confidential medical information and will be maintained as per our HIPAA guidelines. We will never share any of your information without explicit permission. Please let us know if you need copies of your patient file.
Today's DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this for a New Patient or Info update
Patient Name

First NameMiddle NameLast Name
Are you the patient filling out this form?

No, who are you?
Patient Address

Street Address

CityState

Zip Code
Patient Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Age
Patient Gender
Patient Marital Status
Occupation
Company name or Self-employed
PATIENT/Guardian phone numbers:
Primary or Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Can we text this number?
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Can we text this number?
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Extension
Patient email
example@example.com

Please list your Family so that we might know you better

Physician Info:
Physician's name
Physician's phone number
Format: (000) 000-0000.
Physician's specialty
EMERGENCY Contact:
Emergency contact name
Emergency contact relationship
Emergency contact phone number
Format: (000) 000-0000.
Previous Experiences with Acupuncture?
Have you ever had acupuncture before?
When?
By Whom?
How Many Acupuncture Treatments?
How was the previous acupuncture? Did it help?
Who Refered you and/or How did you hear about our clinic?

(answer as many as relevant)
Medical Professional, who?
Patient of our clinic, who?
Family member, who?
Other, who?
Should be Empty: