About this template
Streamline your clinical intake process with this comprehensive Acupuncture New Client Google Form Template. Designed specifically for licensed acupuncturists, holistic practitioners, and wellness clinic owners, this form gathers critical health background before a patient's first session. It covers essential contact details, emergency contacts, detailed medical history, existing conditions, pain points, lifestyle habits, and targeted body system check-ins.
Collecting thorough intake information ahead of time allows practitioners to review medical histories, identify potential contraindications, and tailor treatment plans effectively. Built-in consent and policy acknowledgments ensure clear communication regarding clinic guidelines. With Doc2Form, you can easily deploy, customize, and share this form to establish an organized, professional onboarding workflow for every new patient.
Key features
- Collect detailed medical history and chief complaints before the first session
- Gather emergency contact and personal information securely
- Includes symptom checklists for pain, digestion, circulation, and more
- Built-in policy acknowledgments and client agreement fields
- Fully customizable to match your clinic's specific intake requirements
Use cases
New patient onboarding for private acupuncture and holistic clinics
Pre-treatment health assessments for integrative medicine centers
Gathering informed consent and medical history prior to wellness ther…
Gathering informed consent and medical history prior to wellness therapies
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Select your birth date.
- Email Address (Short answer)Enter the best email address to reach you for appointment confirmations.
- Mobile Phone Number (Short answer)Enter your primary phone number.
- Home Address (Paragraph)Provide your current residential address.
- Occupation (Short answer)Let us know what you do for work.
- Emergency Contact Name and Phone (Short answer)Who should we contact in case of an emergency?
- How did you hear about us? (Dropdown)Select how you were referred to our clinic.
- Health Fund / Insurance (Short answer)List your health fund provider if you plan to seek reimbursement.
- Main Health Complaint (Paragraph)What is the primary reason for your visit today?
- When did this condition begin? (Short answer)Describe how and when your symptoms started.
- Have you received acupuncture before? (Multiple choice)Select your prior experience with acupuncture treatments.
- Current Medications and Supplements (Paragraph)List any prescription medications, OTC drugs, herbs, or vitamins you currently take.
- Known Allergies (Short answer)List any allergies, including sensitivities to topical oils, latex, or metals.
- Past Operations, Injuries & Health History (Paragraph)Describe any major surgeries, hospitalizations, or significant injuries.
- Clinic Policy Acknowledgment (Short answer)Type your full legal name to confirm you have read and agree to our cancellation and privacy policies.
- Newsletter & Wellness Updates (Multiple choice)Would you like to receive wellness tips and clinic updates via email?
- Submission Date (Date)Enter today's date.
FAQ
How can I share this form with my new clients?
Once you convert and save this template to your Google Drive, you can easily send clients a direct link via email, text, or embed it directly on your clinic's website.
Is this acupuncture intake form customizable?
Yes! Because it lives in your Google Forms account, you can freely add, remove, or edit questions to match your specific clinical practice and modalities.
Can patients complete this form on their mobile phones?
Absolutely. Google Forms are fully responsive and optimized for smartphones, tablets, and desktop computers, making it simple for clients to fill out prior to their appointment.
How do I collect client signatures or policy agreements?
The form includes acknowledgment checkboxes where clients confirm they have read and agreed to your clinic policies and treatment terms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.