Name
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First Name
Last Name
Date
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Email
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Age
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Date of Birth
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MM
DD
YYYY
Gender
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Marital Status
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Single
In a Relationship
Married
Divorced or Separated
Widowed
Education
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Grammar School
High School
College
Masters
Doctorate
Other
Occupation
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Insurance Provider
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Member ID
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Policy Holder
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First Name
Last Name
Policy Holder Date of Birth
MM
DD
YYYY
Emergency Contact
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First Name
Last Name
Relation
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Emergency Contact Phone
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(###)
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Referred By
Have you ever been treated by acupuncture or Oriental medicine before?
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What are your primary reason(s) for coming in for treatment?:
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Describe the onset of the primary concern:
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If applicable, have you been given a diagnosis for your primary concern? If so, what diagnosis and by whom?
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What other kinds of treatment have you tried?
How is your sleep?
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How is your digestion?
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List medications or supplements you are taking:
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Allergies (drugs, chemicals, metals, foods):
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List serious illnesses, accidents, or surgeries:
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Other concerns?
Do you follow any type of special diet (i.e. vegetarian, vegan, medical related, or other)?
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If yes, what type of diet?
Please indicate any painful or distressed areas by selecting an area:
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Other painful areas not listed:
Check conditions you have or have had in the past:
Check symptoms you have or have had in the last year:
Skin Disorders
Genital/Urinary Disorders
Eyes/Ear/Nose/Throat/Respiratory Disorders
Reproductive and Gynecologic Disorders
Could you be pregnant?
Number of Pregnancies
Number of Live Births
Number of Miscarriages
Number of Abortions
Duration of Menses
Muscle, Joint, and Bone Disorders
Swollen Joints, Pain, Weakness, or Numbness in any of the following areas:
Cardiovascular Disorders
Gastrointestinal Disorders
Additional Comments
By initialing below, I do hereby voluntarily consent to be treated with acupuncture, Asian bodywork, cupping and/or herbs from the Oriental Materia Medica by a licensed acupuncturist at Pan Healing Wellness Center. I understand that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that lasts a few days. In addition, some points may temporarily bleed after needles have been removed. I understand that if I opt for cupping therapy the cups may leave non-painful bruise marks where the cups were located. I understand that acupuncturists practicing in the state of Massachusetts are not primary care providers and that regular primary care visits by a licensed physician are recommended by this clinic's practitioners. I understand that all information written in this intake form, information entered into my HIPAA-compliant electronic medical record and given verbally to my practitioner(s) will be kept confidential.
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Pan Healing will do our best to verify your insurance coverage and copay, or deductible. However, please know that insurance coverage is never certain until your claim is returned to us. Please reach out to your insurance company with any questions as it is often more easily obtained as the member than the provider. If we do not have the correct insurance information within 30 days of your visit the insurance will deny the claim. It will then be your responsibility to collect payment from the insurance company and pay out of pocket for your session at Pan Healing. If for any reason there is a balance remaining after your insurance company's payment, you will be sent a statement from Pan Healing. Your full portion of the bill is expected to be paid when payment is received from your insurance carrier. We will submit an invoice for any unpaid balances. Invoices are due to be paid within 30 days.
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An out-of-pocket/self pay session is $120. You can also opt to pay that full rate until we receive back your first claim and see how your insurance has accepted it. In the case that you have overpaid, we will give you a refund. Thank you for your understanding.
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Cancellations and rescheduling must be done 48 hours in advance of your first/initial visit. We require 24 hours notice for all follow ups. If you late cancel for your visit, you will be charged a $60 late cancellation fee
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We accept flex spending, health spending accounts, cash, checks, Visa, MasterCard, and Discover. We value you as our patient and want to maintain a positive relationship. Please let us know if you have any questions regarding our payment policy.
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