General Intake Forms (For everyone to fill out.)

Please fill out each of these forms prior to your appointment at Blossom Clinic. You can scan them back to us or bring them in with you.

HIPAA (short form)

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New Client Info

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Consent To Treat Blossom Acupuncture

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Health History Forms (Choose ONE of the following.)

Please choose one of these forms and fill it out prior to your appointment at Blossom Clinic. You can scan them back to us or bring them with you. We look forward to meeting you!

Female Fertility Acupuncture

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Pregnancy Acupunture

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Male Fertility Acupuncture

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General Health History AcupunctureFor health concerns other than fertility or pregnancy

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Other Forms

Please use the Insurance Verification Form if you would like to check your “out of network“ acupuncture benefits. We are a fee-for-service clinic and if you have out of network coverage, we will provide a superbill for each session that you can submit to your insurance company. Email us if you have any questions! We’re here to help.

Please also find the HIPAA form here. You do not need to sign this one.

Insurance Verification

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Long HIPAA Form

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