Level 1 75 Willoughby Road, Crows Nest, NSW, 2065 Phone: 02 8095 8255 www.classicalacupuncture.com.au

Initial Consultation Form:

All information is strictly confidential

Name: ________________________________________D.O.B _________

Address: _____________________________________________________

_____________________________________________________________

Phone: Home / Business:___________________Mobile:________________

Email:__________________________Occupation:____________________

Health Fund:____________________________Referral:________________

Medical History:

Previous Surgery:_______________________________________________

Previous and / or Current Major Illness:_____________________________

_____________________________________________________________

Are you pregnant or trying to conceive? Yes No

Current Medications and / or supplements: __________________________

_____________________________________________________________

Main Reason for visit: ___________________________________________

Do you understand and agree that any missed appointments will be

charged at the full rate and that any cancellations within 24 hours will incur

a charge of 50% of the scheduled appointment fee? Yes No

Signed: ______________________________ Date: ___________________