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: ___________________