Forms to Complete

Please print and complete ALL of the forms in the links below, and bring them to your first acupuncture visit. If you do not have a printer or need to fill them out once you arrive, please email us to let us know you will be arriving 30-40 minutes early to complete the forms, and we will have them waiting and ready for you when you arrive. ***PLEASE NOTE: AS WE ARE SPECIALIZING IN WOMEN’S HEALTH, WE ARE NO LONGER ACCEPTING NEW MALE PATIENTS UNLESS IT IS FOR MALE FACTOR FERTILITY AND YOU ARE THE PARTNER OF A FEMALE COMING FOR FERTILITY TREATMENT. IF YOU ARE A MALE PATIENT AND YOU NEED A RECOMMENDATION, WE ARE HAPPY TO HELP!

It often takes people up to 30 minutes to complete all forms, so we recommend not waiting until the last minute!

  • FERTILITY PATIENTS PLEASE NOTE THAT YOU HAVE AN EXTRA FORM TO COMPLETE, OUTLINING YOUR FERTILITY HISTORY.
  • INSURANCE PATIENTS: PLEASE NOTE THAT IF YOU WISH US TO BILL INSURANCE, YOU MUST ARRIVE WITH THE LAST FORM COMPLETED, SO THAT YOUR INSURANCE HAS BEEN VERIFIED BEFORE YOUR VISIT. OTHERWISE WE WILL JUST ASSESS THE SELF-PAY RATE UNTIL THE TIME AT WHICH YOUR INSURANCE HAS BEEN VERIFIED.

Acupuncture Treatment Forms:

New Patient Initial Intake Form

Consent to receive Treatment w. cancel policy

HIPAA

CO Disclosure Statement

For Fertility patients ONLY, please also fill out the following appropriate form for male/female: **please note that we only specialize in helping women get pregnant naturally–if you will also be starting ART/IVF we will refer out to another clinic

New Patient Fertility History for FEMALE

New Patient Fertility History Intake for MALES

For patients wishing to bill insurance:

Insurance Verification and Financial Agreement (For those patients wishing to bill their insurance: Complete this form by calling your insurance and asking the questions provided, and bring it to your first acupuncture appointment along with your insurance card. If you do NOT arrive at your first appointment with this form completed, we will simply apply the self-pay fee at the time of your visit, until the time at which your coverage has been verified) *Please note that even if your plan includes acupuncture benefits, some plans only cover limited conditions*

 

 

Wisdom Ways Acupuncture ~ 363 W. Drake Road Suite 1, Fort Collins, CO 80526 ~ (970) 227-3077