New Patient Intake Form

Welcome to Acupuncture Northwest & Associates. Please complete the form below prior to your appointment. Please note that all information is strictly confidential.

Location Preference
Patient Information



All care related correspondence must be done via phone.
In Case of Emergency Contact
Family Physician
Insurance Information

If Acupuncture Northwest & Associates will be billing your insurance, please fill out the following:

Reason For Visit
Your Medical History
Family Medical History


Medications/Vitamins/Supplements
Medications Reason When & For How Long
Lifestyle









Body Systems Review

Thank you for taking the time to fill out this form thoroughly. It will help us serve you better.