Secure & Confidential Patient Information Sheet

Part 1 of 2

…You may fill this out prior to your visit to expedite the intake process. The information on this form is securely submitted and stored. Y. Frank Aoi uses the information on the form to create a patient profile for the sole purpose of medical treatment. At no point, will any of the information be used for marketing purposes or sold to a third party. We do collect certain data, but not through this form. Please see the website privacy policy for further details.

If you prefer, here is a PDF version of this form you can download and print. Right-click the link below and select “Save Link As”.

Download Intake Form (PDF)

General Information



MaleFemale



NoYes


NoYes

Emergency Contact

Medical History


NoYes


NoYes


YesSomewhatNot MuchNo


NoYes, Please specify:

How Did You Hear About Japan Acupuncture?

Internet SearchWalk-inAdvertisementReferred By:

Pin It on Pinterest