Edina
7550 France Ave S.
Suite #240, 55435
952-830-8107
Burnsville
14031 Burnhaven Dr.
Suite #106, 55337
952-746-1480
Minneapolis
2545 Chicago Ave S.
Suite #G10, 55404
612-353-6318
St. Paul
393 N. Dunlap Street
Suite #730, 55104
651-528-8884
Patient Information
Name____________________________________________ F___M___ Birth Date _____/_____/______
Street Address___________________________________City_________________State____ZIP___________
Home Phone_____-_____-______ Mobile Phone _____-_____-______ Work Phone _____-_____-______
Email Address________________________________________ Preferred contact method_________________
Primary Insurance Company___________________________________________________________________
Secondary Insurance Company_________________________________________________________________
Occupation__________________________________________Employer Name_________________________
Emergency Contact__________________________Phone _____-_____-______ Relationship______________
Primary Physician____________________________________Clinic Name_____________________________
Other Referring Physicians and /or Healthcare Providers:
Name___________________________Specialty____________________Clinic Name____________________
How did you hear about Chinese Acupuncture & Herb Center?
Referral: Physician ____ Physician Name ______________________ Clinic Name ___________________
Recommendation:
Online:
Other Patient_____
Our Website____
Friend_____
Facebook____
Name______________________________
WebSearch____
Insurance website____
Other (please explain) ______________________________________________________________________
Signature_______________________________________________________ Date_____/_____/______
Edina
7550 France Ave S.
Suite #240, 55435
952-830-8107
Burnsville
14031 Burnhaven Dr.
Suite #106, 55337
952-746-1480
Minneapolis
2545 Chicago Ave S.
Suite #G10, 55404
612-353-6318
St. Paul
393 N. Dunlap Street
Suite #730, 55104
651-528-8884
Patient Health History
Name__________________________________________
F____M____ Birth Date____/____/______
Why you are seeking Acupuncture today: ________________________________________________________
Have you received a diagnosis for this condition? ___Yes____No Diagnosis____________________________
Are you under the care of another health care provider/physician for this condition? _____Yes
Have you had acupuncture therapy before today?
_____Yes
_____No
_____No
Please describe your general health: ____________________________________________________________
Please circle any of the following conditions which are part of your medical history
Aids/HIV
Allergies
Anxiety
Arteriosclerosis
Asthma
Arthritis
Cancer
Chemical Dependency
Depression
Diabetes
Emphysema
Fibromyalgia
Heart Disease
Heart Attack
High Blood Pressure
Hepatitis
Seizure
Stroke
Thyroid Disorder
Trauma
Ulcers
Venereal Disease
Other Conditions
_______________
Please list all previous surgeries (types and dates): ________________________________________________
__________________________________________________________________________________________
Please list all of your current medications below (Prescription, over the counter, and supplements/herbs)
__________________________________________________________________________________________
__________________________________________________________________________________________
List all drug and food allergies_________________________________________________________________
Signature_____________________________________________________________Date_____/_____/______
Edina
7550 France Ave S.
Suite #240, 55435
952-830-8107
Burnsville
14031 Burnhaven Dr.
Suite #106, 55337
952-746-1480
Minneapolis
2545 Chicago Ave S.
Suite #G10, 55404
612-353-6318
St. Paul
393 N. Dunlap Street
Suite #730, 55104
651-528-8884
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT FORM
Print your name __________________________________________________________________________
I acknowledge that Chinese Acupuncture & Herb Center has provided me with a copy of the Chinese
Acupuncture & Herb Center Notice of Privacy Practices document. I understand this form means only that I
have received the Notice, and in no way affects the care I receive at Chinese Acupuncture & Herb Center. In
accordance with the United States Federal Government HIPPA rules, please sign this document and return it to
the front desk.
Signature____________________________________________________________Date____/____/______
Relationship to patient (if signature is not that of patient) _________________________________________
CONSENT FOR USE OF DISCLOSURE OF HEALTH INFORMATION
You have the right to request that we do not disclose your health information to specific individuals, companies,
or organizations. You may revoke any of your authorizations at any time; however your revocation must be in
writing. You have a right to refuse consent for disclosure of your personal health information. Without your
consent, however, we will not be able to submit clams to insurance carriers or other third party payers and may
not accept you as a patient.
*By signing below, I give my consent to Chinese Acupuncture & Herb Center to disclose my personal
health information.
Printed Name______________________________________________________________________________
Signature _______________________________________________________________Date____/____/_____
Authorized Provider Representative __________________________________________Date____/____/_____
Edina
7550 France Ave S.
Suite #240, 55435
952-830-8107
Burnsville
14031 Burnhaven Dr.
Suite #106, 55337
952-746-1480
Minneapolis
2545 Chicago Ave S.
Suite #G10, 55404
612-353-6318
St. Paul
393 N. Dunlap Street
Suite #730, 55104
651-528-8884
Informed Consent
I have made a personal choice to receive treatment at Chinese Acupuncture & Herb Center using acupuncture,
moxibustion, cupping, Chinese herbs, or other methods of Traditional Chinese Medicine. I understand that no
promises or guarantees can be made regarding the outcome of treatment because of the uniqueness of each
individual.
I have been informed that all practitioners at Chinese Acupuncture & Herb Center have had appropriate
education and are licensed by the State of Minnesota. The scope of practice under acupuncture licensure
includes using Oriental Medical theory for diagnosis, and for development of a treatment plan. Techniques may
include insertion of sterile needles, electro-stimulation, heat, cupping, dermal friction, acupressure, herbal
therapies, dietary counseling, breathing techniques, and exercise; all of these according to Oriental medical
principals.
I have been informed that while side effects are not common, they may include some pain in the treatment area,
minor bruising, temporary faintness, possible worsening of some symptoms for 24/48 hours before
improvements begins, possible broken needles, and as with any procedure in which the skin is broken, a very
slight risk of infection. I have been informed that the needles are sterile.
I understand that it is appropriate for me to consult my primary care physician about the acupuncture treatment
if I choose to do so, if circumstances warrant, and/or if my acupuncturist recommends such a consultation.
I understand that I should inform my acupuncturist whether I have been examined by a licensed physician with
regard to my presenting complaint, and if so, what the western medical diagnosis is. I should also report
whether I have any other serious illness, a bleeding disorder, or a pacemaker.
Printed Name______________________________________________________________________________
Signature_______________________________________________________________Date____/____/______
Edina
7550 France Ave S.
Suite #240, 55435
952-830-8107
Burnsville
14031 Burnhaven Dr.
Suite #106, 55337
952-746-1480
Minneapolis
2545 Chicago Ave S.
Suite #G10, 55404
612-353-6318
St. Paul
393 N. Dunlap Street
Suite #730, 55104
651-528-8884
Financial Policies
 If your insurance policy offers acupuncture coverage, we will gladly submit the claims
for you. We can advise you on your insurance benefits, but we cannot guarantee
payment from your insurance company.
o You are responsible for your deductible, your co-pay and co-insurance.
o If your insurance denies payment of your claim, you will be held responsible for
the charges.
 Without insurance coverage, you will be responsible for paying the charges at the time of
treatment. The charge for the initial visit includes both the initial consultation charge and
the acupuncture charge listed below.
o Initial Consultation $45
o Initial Consultation with Dr. Hu $75
o Acupuncture Treatment $75.00
By signing below you are agreeing to the above policies, and accepting financial responsibility
for your treatments.
Signature_________________________________________Date____/____/_____