Existing Patient Update

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    Pain Assessment



    Current Ailments

    HeadNeckShoulder (Right)Shoulder (Left)Elbow (Right)Elbow (Left)Wrist (Right)Wrist (Left)Hand (Right)Hand (Left)Hip (Right)Hip (Left)Knee (Right)Knee (Left)Ankle (Right)Ankle (Left)Foot (Right)Foot (Left)Leg (Right)Leg (Left)Back (Upper)Back (Mid)Back (Lower)

    PainLoss of Use/MovementAltered Sensation


    I do hereby authorize the Doctors & Licensed Acupuncturists of Premiere Healthcare to administer such care that is necessary for my particular condition(s). This care may include, but are not limited to, review of medical history, examination, acupuncture, herbal medicine, spinal or extremity adjustments, soft tissue or manual therapies (myofascial release, cupping, gua-sha, tui-na, qigong), physiotherapy modalities (ice, heat, electric stimulation), nutritional and lifestyle counseling and/or laser therapy that is advisable, and necessary for my health condition(s).

    I understand, that if recommended, herbal medicine needs to be prepared and teas need to be consumed according to instructions provided orally and in writing. The herbs may have unpleasant smell or taste. I will immediately notify my practitioner or clinical staff member of any unanticipated or unpleasant effects associated with the treatment or consumption of herbs.

    Furthermore, I authorize and agree to allow the Doctors & Acupuncturists of Premiere Healthcare to work with my health condition(s) through the use of acupuncture needling, spinal adjustments, various soft tissue or manual therapies, physiotherapy modalities, nutritional supplements, herbs and homeopathic remedies, rehabilitative exercises and/or laser therapy for the sole purpose of postural and structural restoration to allow for normal biomechanical and neurological function. I have had an opportunity to discuss with one of the Doctors or Acupuncturists of Premiere Healthcare and/or with other office or clinic personnel regarding the nature and purpose of recommended treatment and other procedures related to my health care.

    I understand that I am responsible for all fees incurred for the services/products/durable medical equipment provided and agree to ensure full payment of all charges. I further understand that a fee for services or products rendered will be charged and that I am responsible for this fee whether results are obtained or not.

    I understand and am informed that as in the practice of medicine and dentistry, in the practice of Acupuncture, Chiropractic & Oriental Medicine there are risks to treatment including, but not limited to fractures, disc injuries, burns, stroke, dislocations, sprains, headaches, temporary increased soreness or pain, nausea or lightheadedness and emotional release. I do not expect the Doctor or Acupuncturist to be able to anticipate and explain all risks and complications of a given procedure on any visit, and I wish to rely on the Doctor or Acupuncturist to exercise judgment during the procedure which they feel at the time, based upon the facts then known, is in my best interest. The Doctor or Acupuncturist will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the conditions treated at this clinic.

    I understand there are other forms of treatment, including drugs and surgery, which could be treatment options for my condition(s), but at this time, I choose acupuncture, chiropractic, nutrition and/or oriental medicine. I understand that acupuncture or oriental medicine is not a replacement for diagnostic medical procedures and that an Acupuncturist does not diagnose according to standard medical practice. I further acknowledge that my practitioner is not a medical doctor, Doctor of Osteopathy or Doctor of Physical Therapy and does not claim to practice within the scope thereof.


    Your appointments and well-being are very important to us. We understand that sometimes unexpected delays can occur, making schedule adjustments necessary. If you need to cancel or change your appointment, we require a 48 Hour Notice, prior to your scheduled appointment so that we may have time to offer the opening to another patient.

    By scheduling appointments, you agree to the terms of our no-show/late cancel/ late reschedule policy.
    We reserve the right to charge a Cancellation Fee of $50 for all appointments cancellations or late rescheduling (less than 48 hours prior). We cannot bill your insurance for no shows.

    Cancellation fees will be charged to your card on file the day of your scheduled appointment. If no card on file, payment of cancellation fee will be required prior to securing your next appointment. Repeated violations of our cancellation policy will result in the patient being required to pay the full price of any scheduled services upfront or upon any cancellation with less than 48-hour notice.

    By submitting this form you acknowledge and agree to the above terms and conditions.   

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