* You are invited to pre-fill the following form prior to your visit to our clinic. However it is not compulsory to do so. Alternatively, you are welcome to fill in the paper form upon your first visit to the clinic.

Client Form

Sex

How did you find out about this clinic

Medical insurance

Previous acupuncture

Relevant past health history (tick all relevant items):

Clinic

Do you have pains?

According to the diagrams above, tick all areas where you currently feel pain:

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