raleighacupunctureandlaser.com

New Patient Intake Form

Raleigh Acupuncture and Laser
Please complete this form prior to your first visit so we can provide you with the best possible care.
Patient Information
Full Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method

PhoneEmail
Emergency Contact
Name
Relationship
Phone
Please enter a valid phone number.
Primary Concerns
Please describe the key areas you would like Dr. Hightower to address
Current Symptoms / Conditions

PainNumbness/TinglingMuscle WeaknessHeadaches/MigrainesStress/AnxietyFatigueDigestive IssuesSleep ProblemsOther
Relevant Medical History
Please list any past or current medical conditions, surgeries, or injuries
Medications & Supplements
Please list all current prescriptions, over-the-counter medications, and supplements
Openness to Care
This clinic offers natural, drug-free healing through Neuropuncture, Acupuncture, and Class IV Laser Therapy. To take full advantage of these therapies, we encourage you to be open-minded and ready to explore new possibilities for healing.
Do you feel ready to approach your healing with openness and trust?

YesNoUnsure
Consent to Care
I understand that my care will focus on natural, non-invasive therapies and that results may vary. I give my consent to receive treatment
Signature

Clear
Date

MonthDayYear
Date
Instructions for Your First Visit
1. Complete this form thoroughly, focusing on the key areas you want addressed.
2. Come ready to rethink what is possible for your health and healing.
3. Wear loose, comfortable clothing for your session.
We look forward to seeing you soon!
Should be Empty:

New Patient Intake Form

Patient Information

Emergency Contact

Primary Concerns

Relevant Medical History

Medications & Supplements

Openness to Care

Consent to Care