Patient Intake Form

Please complete this form before your first appointment

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Phone Number *

Email Address *

Address

City

State

Zip Code

Emergency Contact

Contact Name *

Contact Phone *

Relationship *

Medical History

Primary Reason for Visit *

Current Medications

Allergies

Past Surgeries or Hospitalizations

Existing Medical Conditions

Are you pregnant?

Yes No N/A

Do you have a pacemaker?

Yes No

Insurance Information (Optional)

Insurance Company

Member ID

Consent & Acknowledgment

I consent to acupuncture and/or physical therapy treatment by the practitioners at Bethel Health. I understand the nature of the treatment and have had the opportunity to ask questions. * I acknowledge that I have read and understand Bethel Health's HIPAA privacy practices and agree to the terms. * I consent to receive appointment reminders and health-related communications via phone, email, or text message.

Electronic Signature (Type Your Full Name) *

By typing your name, you agree that this constitutes your legal signature.

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Questions? Call us at (904) 834-9515

or email Bethel.Acupuncture.Health@gmail.com