Patient Health Summary & Intake Form 2026

  • PATIENT HEALTH SUMMARY & INTAKE FORM

  • Pins & Needles Acupuncture 5006A 50 Street Beaumont, AB T4X-1E6 587-206-0435 pinsandneedlesacupuncture@gmail.com Jennifer Peck / R1201459

  • Client Personal Information

  • Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • How do you identify?*
  • Have you received acupuncture treatment before?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • Date of Birth
     - -
  • Rows
  • Rows
  • Do you have a contagious disease (i.e. hepatitis, tuberculosis, AIDS, flu) at this time?
  • Have you ever had surgery or been hospitalized?
  • Are you allergic to any medications, herbs, foods?
  • Please check boxes that are relevant to you pertaining to your cardiovascular conditions:
  • Please check boxes that are relevant to you pertaining to your gastrointestinal conditions:
  • Please check boxes that are relevant to you pertaining to the head, eyes, nose, and throat:
  • Please check boxes that are relevant to you pertaining to your respiratory conditions:
  • Productive cough with:
  • Please check boxes that are relevant to you pertaining to your sleep patterns:
  • Waking up in the night?
  • Energy level:
  • Please check boxes that are relevant to pertaining to the condition(s) of your hair and skin:
  • Please check boxes that are relevant to you pertaining to your genito-urinary conditions:
  • Thirst?
  • Which do you prefer to consume?
  • Please check boxes that are relevant to you pertaining to your neuropsychological conditions:
  • Please check boxes that are relevant to you pertaining to your musculoskeletal conditions:

  • Please check boxes based on body temperature

  • Typically:
  • Limbs:
  • Hands:
  • Feet:

  • Sexual and Reproductive Health:

    (If Applicable)
  • Check if applicable:
  • Do you use birth control pills?
  • Are you pregnant?
  • Have you ever been pregnant?
  • Problems with pregnancy?
  • Problems with delivery?

  • Section II Patient Informed Consent to Treatment

    Jennifer Peck/ R1201459, 587-206-0435

  • By signing this form, I voluntarily consent to be treated by Pins & Needles Acupuncture as administered by Jennifer Peck.I understand acupuncture is performed by the insertion of needles through the skin, by the application of heat to the skin, or by both at certain points on or near the surface of the body in an attempt to restore normal physiological body functions, modify, or prevent pain perception.I have been made aware that Traditional Chinese Medicine (TCM) utilizes a range of modalities including but not limited to acupuncture, moxibustion, cupping, tuina, acupressure, gua sha, and TDP heat lamp. I understand any of these modalities may be used in combination during my treatment sessions.I have been made aware of the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, fainting, temporary pain or discomfort, soreness, bruising, minor bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.I will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.I understand that I must inform my practitioner if I am carrying, or believe I may have, any infectious agents, including but not limited to HIV, TB, and hepatitis. In some cases where cross-infection risk is high, my practitioner may withhold treatment.I understand acupuncture has been safely practiced for centuries, but no guarantees are given concerning the effectiveness of treatments, and I am free to discontinue treatment at any time.I am responsible for full and prompt payment after services have been rendered.I have discussed the content of this form with my practitioner. I acknowledge that I have asked any questions I may have and received answers that I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.I have carefully read and understand all of the foregoing and am fully aware of what I am signing. I understand my responsibilities as a patient.
  • Date Signed*
     - -

  • Consent to Collect and Release Information

    Jennifer Peck/ R1201459, 587-206-0435

  • I         , or my guardian,         

  • For Pins & Needles Acupuncture to collect and release my general patient or medical information to other medical practitioners or health care providers/ support workers, emergency personnel and/ or any other relevant organizations.

  • In terms of information, the Clinic may collect any of the following:

  • • Contact information

    • Personal or family medical history

    • Medical insurance or billing/ account information

  • In cases of emergencies or life-threatening situations, medical or support staff workers may have to collect this information from family members or listed contacts without your prior written consent.

  • How Your Information Will Be Used

  • Your personal information can be used or disclosed for the following reasons:

    • For billing or account purposes
    • To assist third-party insurance companies with insurance claims
    • Referring your medical history to another health practitioner or health care provider
    • To seek advice for potential treatment options
    • To prevent or assist patients in cases of emergencies or threats to their health and safety
    • To fulfill any obligations as mandated by law

  • Patient Access to information

  • I understand that my personal and medical history is available to me for my review under most circumstances. Cases where access to records is limited are:

    • Cases where access to information causes a threat to your life or personal health
    • Where the law disallows access to information
    • If disclosure of information relates to any anticipated or actual legal proceedings or professional conduct proceedings [If applicable] I understand that a reproduction or translation fee may be incurred by the clinic's fee schedule.

  • Acknowledgment

  • I allow medical personnel to use and disclose my information as outlined above. I understand that I can access my personal health information except as outlined above. I understand that I can withdraw my consent at any time, but it may directly affect the services I receive. My personal information can still be used/disclosed if mandated by law.

  • Credit Card on File Policy

  • To help ensure appointment availability for all clients, a valid credit card is required to secure your appointment and will be kept confidentially on file. Your card will not be charged at the time of booking and will only be used in accordance with our Cancellation & No-Show Policy for appointments cancelled with less than 24 hours` notice or missed without prior notice.

    At the time of your appointment, you are welcome to pay using the credit card on file, another preferred method of payment, or through direct billing if your insurance plan is eligible. We appreciate your understanding and cooperation in helping us provide timely care to all clients.

  • Appointment Cancellation & No-Show Policy

  • To provide the highest quality of care and accommodate all clients effectively, Pins & Needles Acupuncture requires a minimum of 24 hours` notice for any appointment cancellation or rescheduling request.


    Appointments cancelled with less than 24 hours` notice will be subject to a cancellation fee equal to 50% of the scheduled service fee. Clients who fail to attend their scheduled appointment without prior notice (a "no-show") will be charged 100% of the scheduled service fee.


    We understand that unforeseen circumstances may occasionally arise. Exceptions may be considered at the discretion of Pins & Needles Acupuncture.

  •  Client Acknowledgement

  • I acknowledge that I have read, understood, and agree to the Cancellation & No-show Policy of Pins & Needles Acupuncture. I authorize Pins & Needles Acupuncture to charge my payment method on file for any applicable late cancellation or no-show fees in accordance with the policy outlined above.

  • Date Signed*
     - -
  • Should be Empty: