New Patient Information Form

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

(###)

###

####

Preferred Pronouns

Referring Physician Name (optional)

Please describe your conditions & symptoms:

Are there aggravating or relieving factors?

How long has this been going on?

Insurance Provider

(optional)

Insurance Policy Number

(optional)

How did you hear about us?

Privacy

This form collects your name, email, phone number, insurance provider, insurance policy number, date of birth and referred practitioner so we can look into your benefits. Your information is shared with our medical billing company in order to verify your coverage.

I consent to having Wellspring Health collect my name, email, phone number, insurance provider, insurance policy number, date of birth and referred practitioner and sharing it with their medical billing company.

CALL, EMAIL, or complete our Patient Information form so that we can schedule your complimentary new patient consultation.

Kirsten or a patient care coordinator will get back to you ASAP.

Please read our STEP-BY-STEP GUIDE FOR NEW PATIENTS or our FAQ to understand more about our process and Acupuncture.

We look forward to hearing from you and participating in your health journey.

Sincerely,

The Wellspring Team

We welcome all LGBTQIA+ identities and offer specialized health care for transgender patients.

We respect your privacy and protect your information.

HIPAA Notice of Privacy Practices

We Would Love to Hear From You

We offer complimentary new patient consultations in-clinic or via phone to explore your care needs. We are privileged to be considered among your healthcare providers.

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