YOUR VISITS- ACUPUNCTURE & MASSAGE

Forms

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Fill in forms online, print, or pick up forms before your appointment to complete. 


Acupuncture:   Traditional Chinese Medicine intake forms are lengthy because the entire body is examined.  By returning your forms a day or two before your appointment, you will ensure a more efficient & shorter Intake appointment.


Massage:  Fill out forms prior to appointment or arrive 15 mins before your appointment time to do so.

Water - Bathroom

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Acupuncture:  Drink extra water for 24 - 48 hours if Cupping or Gua Sha is applied. 


Massage:  Drinking extra water the day before, of & after your appointment will help prevent prolonged soreness, dehydration, & support the lymph system.


Acupuncture & Massage:  Use the facilities prior to your session.  Before you arrive or in office.  It's easier to relax without a full bladder! 

Cleanliness

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Acupuncture:  You will want to be clean for your acupuncture treatment.  All points are swabbed with alcohol before the insertion of needles.  Taking the extra step of being clean will help prevent the risk of infection. 


Massage:  Taking a shower before your appointment is important if you are visibly dirty from working outside or smell like you have been.  During flip flop season you may need to rinse your feet before coming in if you need them worked on. 

Exercise

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Acupuncture:  If Cupping, Gua Sha, Topical Herbal Medicine, Tui Na, or Electro-Stimulation are used, exercise after treatment is prohibited.


Massage:  No exercise after your session. Otherwise, you may have increased soreness, risk injury, or other muscle overuse & dehydration side effects. 

Drugs & Alcohol

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Drugs & Alcohol should not be consumed before or after treatment.  Use can decrease the awareness of pain.  It's important to alert your practitioner to any drug or alcohol use, including prescriptions & OTC meds.


Acupuncture:  Acupuncture has been known to increase the effects of alcohol & should not be consumed the same day as your appointment.


Massage:  Being dehydrated before or becoming dehydrated after can cause or increase possible side effects. 

Infection, Cold or Flu Symptoms

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Acupuncture:  Can help stop the progression of illness, cold or flu symptoms depending on the stage & intensity.  Acupuncture may help resolve sinus infections & other illness symptoms sooner.  Contact your practitioner for evaluation prior to your appointment.


Massage:  Dehydration & lymph movement stress the immune system.   Having bodywork while you are ill will increase the severity & duration of the illness.  

Food

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Acupuncture & Massage:  Having a full stomach can cause you as much discomfort as an empty one!  Blood sugar levels can be influenced by both massage & acupuncture.  Please bring any testing or insulin supplies that may be needed. 

Clothing

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Acupuncture:  Wear clothes that can be rolled up to expose the feet & legs up past the knee.  Hands & arms to above the elbow should also be able to be uncovered.  If points aren't accessible, a gown will be provided.

Skin

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No bodywork on areas that are sunburned, windburned, or infectious.  Eczema, psoriasis, & other chronic or non-infectious skin conditions can usually be worked around depending on the affected area's size, severity, & location.  

Online Forms

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Submit forms online at your own convenience!  Forms have been provided in a secure & private patient portal, that you can fill in & submit online prior to your appointment.  You can also send the practitioner secure messages & schedule appointments.  If you need help with the patient portal please visit the SCHEDULE page for step by step directions.

Paper Forms

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If you're not tech savvy or prefer to fill your forms out by hand, provided below is a link.  Download, Print, Fill Out, & Bring your completed forms to the office before or at the time of your appointment.  You can also pick up forms in the office as well.  

WHICH FORMS DO I NEED?

ACUPUNCTURE

SIGNATURES ONLY

  • Receipt of Notice of Privacy Practices Acknowledgement
  • Arbitration Agreement
  • Acupuncture Consent Agreement
  • Iowa Licensed Acupuncturist Disclosure Statement

HEALTH INFORMATION

  • Acupuncture Questionnaire
  • Acupuncture Checklist
  • Women's Health- Women Only

FERTILITY ACUPUNCTURE

SIGNATURES ONLY

  • Receipt of Notice of Privacy Practices Acknowledgement
  • Arbitration Agreement
  • Acupuncture Consent Agreement
  • Iowa Licensed Acupuncturist Disclosure Statement

HEALTH INFORMATION

  • Women's Health- Women Only
  • Women's Fertility Intake- Women Only
  • Acupuncture Checklist
  • Men's Fertility Intake- Men Only

MASSAGE

SIGNATURES ONLY

  • Receipt of Notice of Privacy Practices Acknowledgement
  • Arbitration Agreement
  • Massage Therapy Informed Consent

HEALTH INFORMATION

  • Massage Therapy Health Information
  • Car Accident Massage Therapy- Car Accident Related Only

OPTIONAL

SIGNATURE ONLY

  • Fire Cupping Informed Consent

REQUIRED FOR ALL TREATMENTS

Notice of Privacy Practices

Our Privacy Practices are detailed as required by HIPPA. Protects patient's Personal Health Information.

Receipt of Notice of Privacy Practices Acknowledgement

Patient's signature for Privacy Practices as described in the document above.

Arbitration Agreement

By signing, you are agreeing to this American Acupuncture Council Arbitration Agreement, you are agreeing to settle any malpractice complaints in legal arbitration rather than in court.  Costs for such proceedings will be paid for by both parties no matter the outcome. Intended to prevent frivolous lawsuits.

REQUIRED FOR ALL ACUPUNCTURE TREATMENTS

Acupuncture Consent Agreement

By signing, you are consenting to all forms of treatments associated with the practice of Traditional Chinese Medicine the practitioner is permitted to perform.

Iowa Licensed Acupuncturist Disclosure Statement

Signature required by the Iowa Board of Medicine, licensing board for acupuncturists. This details service rates. The practitioner's education, degrees, certificates, & scope of practice as defined by the Iowa Board of Medicine are also included.

ACUPUNCTURE INTAKE FORMS

Acupuncture Questionnaire

Required details for all new acupuncture patients EXCEPT those seeking FERTILITY treatment.

Acupuncture Checklist

Required details for all new acupuncture patients, including Men's Fertility patients.

Acupuncture Questionnaire & Checklist

Printable combination of both Questionnaire & Checklist.

Acupuncture Women's Health

Required details for all new female acupuncture patients, including FERTILITY patients.

FERTILITY ACUPUNCTURE INTAKE FORMS

Women's Fertility Intake

Required only for women seeking acupuncture for fertility issues.

Men's Fertility Intake

Required only for men seeking acupuncture for fertility issues.

REQUIRED FOR ALL MASSAGE TREATMENTS

Massage Therapy Informed Consent

Consent signed that details the benefits, possible side effects, & contraindications for Massage Therapy.

MASSAGE INTAKE FORMS

Massage Therapy Health Information

Patient details their health information concerning the condition(s) they are seeking treatment for.

Car Accident Massage Therapy

Only patient's seeking services after being in a recent car accident for detailing the circumstances.  Massage Therapy Health Information also required.

OPTIONAL TREATMENT FORMS

Fire Cupping Informed Consent

Signed for Cupping Therapy.

Press Balls, Vaccaria Seeds, & Intradermal Needles

Signed for Auricular Therapy.

Herbal Consent to Treat

Signed for Herbal Therapy.

Home Use of Moxibustion

Signed for Moxibustion use.