Name

First Name

Last Name

Date of Birth

YYYY

Cell Phone

(###)

###

####

Address

Gender

Male

Female

Occupation

Referred By

Emergency Contact (Name and Phone Number)

Health Concerns In Order of Importance

Do You Use

Herbs

Homeopathics

Alcohol

Tobacco

Are You Seeing Your Physician For This Problem?

Yes

Are You Seeing

Chiropractor

Physical Therapist

Psychiatrist

Are You on a Special Diet? If so, Please Describe

Are You a Vegetarian?

Yes

SIGNIFICANT HEALTH HISTORY-Including surgery, past accidents/injuries, family history, and diagnoses:

ALLERGIES- medication, food, environmental:

NAMES OF ALL DRUGS AND MEDICINES YOU ARE NOW TAKING:

MINERALS, VITAMINS, HERBAL, HOMEOPATHIC SUPPLEMENTS:

For MEN Only

weak urine stream

prostate trouble

discharge from penis

painful or swollen testes

For WOMEN Only

menstrual trouble

vaginal discharges

hot flashes

breast lump or discharge

For WOMEN Only: Date of Last Period

For WOMEN Only: # of pregnancies

For WOMEN Only: # of miscarriages

For WOMEN Only: # of abortions

Fees

Dr. Wu's initial 90 minutes appointment fee: $550 (30 min consulation fee: $300 and 60 minutes Tui Na fee: $250). Other practitioners' initial 90 minutes appointment fee: $300 (30 minutes consulation fee: $100, and 60 minutes Tui Na fee: $200). If you require a customized herbal formula for internal use: Customized herbal extract formula ( capsule or powder form): $320/30 days formula. Our goal is to bring a healthy lifestyle and a smile to each client's face, from the very first visit. Note: If a patient or client is not satisfied with their initial visit, they don't have to pay for the initial consultation and initial Tui Na service. After the initial visit, if you are happy to pay for our services, we can not offer any refund afterwards. We only service patients and clients who are happy with our service, because we can not guarantee anything for tomorrow. Tomorrow is a mystery, and today is a gift. We believe in the power of now, where everything is in your hand.

Appointment & Cancellations

By filling out this new patient intake form you agree to opt in to receive contact from us via call, text or email concerning your appointment. We understand that circumstances occasionally arise that will change your plans. You may cancel at no charge if you call at least 24 hrs. before your appointment. If you do not cancel or fail to come for your appointment, a fee of $200.00 will be charged. If you make up your apt. within a week your fee will be waived.

Disclaimer

This modality known as “Qi Gong Tui Na Therapy, Moxabustion, Quantum Energy Medicine” is an ongoing study, being followed by the Taoist Institute of TCM. The practice of energy therapy has never been adequately researched and/or tested in the United States by modern scientific methods. As such, no guarantees or promises as to results and/or to the effectiveness of this modality are offered or implied. This modality is considered to be experimental and in no way should take the place of traditional medical consultation or care. I understand that there is a small chance that moxabustion will cause a blister to form and leave a scar for some patients. This is part of the body healing and no treatment is needed for the blister. If you are worried about the blister popping, simply put a band-aid over the blister and it will heal with time. I have read and understand these guidelines and agree to the terms therein. I give permission to receive email and phone call or text from Wu Healing Center.

Patient Signature (or legal guardian if patient is a minor)

Date

New Patient Intake Form