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Printable Client Intake Forms

Please print out the 5 forms below and use a pen to write in your responses.

It is important to remember to bring them with you to your first appointment.


1. Inner Rivers Acupuncture Intake Forms  

2. COVID-19 Informed Consent Form

3. Informed Consent to Treat Form

4. HIPAA Notice and Agreement

5. Health Information and Privacy Notice (your copy)


Feel free to bring a copy of any medications you are taking or test results to your first appointment as well.


Due to Covid-19 we are encouraging you to fill out your forms at home when possible. If you cannot print and complete the forms at home please let me know in advance and arrive 20 minutes before your appointment. A copy of the forms will be made available for you in the wait area.



(360) 296-6633 Directions Contact/Schedule