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1 Contact Information 2 Health Survey 3 Pain / Female Related Questions 4 Qi Spot Policy & Consent to Treatment
CONTACT INFORMATION

Name * First Last
Birth Date * MM / DD / YYYY
Gender
Male Female
Phone Number * ### - ### - ####
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Occupation
Date of first visit MM / DD / YYYY
Do you have a GROUPON, LIVING SOCIAL or GOOGLE OFFER coupon for your first appointment? *
yes no
Please put in Coupon Number so you do not have to print it out. Coupon numbers will be verified.

Groupon Coupon Number
Living Social Coupon Number
Google Offer Number
INSURANCE INFORMATION

Do you have Insurance that cover's Acupuncture?
yes no not sure
As an insurance patient, you are responsible for knowing your benefits including whether you are covered for Acupuncture, deductibles, copays, coinsurance and limits.

PLEASE NOTE: BENEFITS QUOTED BY YOUR INSURANCE COMPANY ARE NEVER A GUARANTEE OF PAYMENT.

If you answered "Yes" or "Not Sure", what is your PRIMARY INSURANCE COMPANY? If you are not sure whether you are covered for Acupuncture, we will call and verify for you.
Policy Number
Group Number
Phone Number of Insurance Company (usually on the back of the card) ### - ### - ####
Claims Mailing Address of Insurance Company including City, State & Zip Code - (usually found on the back of the card)
SECONDARY INSURANCE COMPANY
Policy Number
Group Number
Phone Number of Insurance Company (usually on the back of the card) ### - ### - ####
Claims Mailing Address of Insurance Company including City, State & Zip Code - (usually found on the back of the card)
EMERGENCY CONTACT

Name First Last
Emergency Contact Phone Number ### - ### - ####
Your Physician Name
Physican's Phone Number ### - ### - ####
Reason for your visit
Allergies / Special Health Considerations
Check any illness or conditions you have or have had in the past.
High Blood Pressure Tuberculosis Depression None
Is there anything else you'd like to tell us about your past medical conditions?
How did you hear about The Qi Spot?
Referred by a family member or friend Referred by my Doctor or Insurance Company Internet Newspaper or Magazine Sidewalk Sign Groupon Coupon Living Social Coupon Other
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