NEW PATIENT FORM

Artemis Morris, ND, MS, L.Ac (Dipl. NCCAOM)

www.drartemis.com
610-882-4325 phone
610-332-0322 fax

Healing Hands
518 Main street
Bethlehem, PA 18018
www.healinghands.com

SERVICES PROVIDED:
Facial Rejuvenation Acupuncture.
$160 one hour appointment.
12 sessions for the series.
Maintenance: Monthly or seasonally, & as needed.
Nutritional consultation/Naturopathy.
First visit $220 one hour appointment.
Return visits $110 for 30-45 minute followup.
Group Acupuncture sessions.
$50 for a half hour session with up to 3 people in a group setting.
Private Acupuncture sessions.
First visit $180 one hour appointment.
Return visits $90 45-60 minute visits.
Appointments made through Healing Hands. Visits are not covered by
insurance.
Cancellation policy: Missed appointments will be charged unless notified of
changes within 24 hours of visit.
Please fill out this form prior to your first visit and
bring it to your practitioner.
Thank you.

PRIVACY PRACTICE & CONSENT FORM

I, __________________________________________________ understand that by its
very nature acupuncture and other modalities of Chinese Medicine (including but not
limited to, acupuncture, acupressure, massage, herbs, aromatherapy, direct and indirect
moxabustion, cupping, and electrical stimulation) may cause minor discomfort, and may
irritate the skin or leave a mark, bruise, or burn. I hereby request and consent to the
performance of the following on myself (or the patient named below, for whom I am
legally responsible): Acupuncture and other Oriental medical procedures including
diagnostic techniques such as questioning, pulse evaluation, palpation of a variety of
areas of my body, observation, range of motion, muscle and orthopedic testing; modes
of manual or physical therapy such as body work, manipulation of joints and/or viscera,
heat and/or cold therapy and electrical and/or magnetic stimulation; cupping and/or
moxibustion; health and dietary recommendations; exercise advice and healthy lifestyle
recommendations. I understand I have opportunities to discuss with my licensed
practitioner and/or with other clinic personnel the nature and purpose of acupuncture
and Oriental medical procedures. Although I am aware that acupuncture and the other
procedures used in Oriental medicine have helped millions of people, I understand that
no guarantee of cure or improvement in my condition is given or implied. I understand
that the minor risks include, but are not limited: bleeding, bruising, pain or other strong
sensation at the location of where a needle is inserted or radiating from that location,
nerve pain, burns, aggravation of current symptoms, appearance of new symptoms and
general aches. I acknowledge that I have been advised to see a physician for my
medical condition(s) if needed. I have read, or had read to me, this informed consent
form. I have also had an opportunity to ask questions about its content, and by signing
below I agree to the above named procedures and conditions of treatment. I intend this
consent form to cover the entire course of treatment for my present condition and for
any future condition(s) for which I seek treatment with Artemis Morris, ND, MS, L.Ac.
I am aware of the Notice of Privacy Practices and I have been provided an opportunity
to review it. Signature denotes understanding and agreement with all statements
above.
__________________________________
___________________
Patient Printed Name
Date
THIS SECTION FOR FOR FACIAL REJUVENATION ONLY:
I do not have any of the following contraindications for this treatment: High blood
pressure, recent migraine headaches, uncontrolled diabetes, cancer, hepatitis, AIDS,
hemophilia, a pituitary tumor, current allergy, current herpes outbreak, high risk
pregnancy, intoxication or hangover from drugs or alcohol.
Explanation____________________________________________________________
________________________________
___________________
Patient Printed Name
Date

NEW PATIENT FORM

Name: __________________________ Date of Birth: _____________ Date: ________
Address:________________________________________________________________
________________________________________________________________________
_________ city, state. Zip code _________________________________________
Phone Number:
(home)__________________(work)_________________(mobile)__________________
Email address:
__________________________________________________________
I would like to receive your free newsletter_________. You can sign up for the free
newsletter on www.revivewellnesscenter.com
Occupation:
_______________________________________________________________________
Primary care physician (name, location & phone number):
________________________________________________________________________
______________________________________________________________________
Permission to contact you regarding reminder calls or updates (please indicate preferred
method)_________________________________________________________________
Allergies:________________________________________________________________
____________________________________________________________________
Have you been under the care of a holistic practitioner or Acupuncturist before?
________________________________________________________________________
________________________________________________________________________
Referred by:________________________________________________________
What are your chief health concerns and reasons for this visit?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please list current medical conditions with dates of diagnosis:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you had or are you currently undergoing any cosmetic procedures? Explain.
________________________________________________________________________
________________________________________________________________________
Current medications & supplements (Please include dosages and brands):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PASTMEDICALHISTORY:(check boxes if yes and include date)
Cancer_________ Diabetes (Type I or II) _________
High blood pressure ___________ Heart disease __________
Hepatitis ____________ HIV/AIDS __________ Lung disease _________ Arthritis
______________ Rheumatic fever____________Thyroid disease______________
Seizures_____________ Ulcers_________ Other_______________________________.
Occupational & environmental stress (physical, psychological, chemical exposure, etc.):
________________________________________________________________________
________________________________________________________________________
Date of last physical examination: _______________
Date of last Pap smear: ______________ Date of last mammogram:_________________
Last laboratory/Blood work (date and significant results):
________________________________________________________________________
________________________________________________________________________
Your birth history (prolonged labor, forceps delivery, etc.)
________________________________________________________________________
________________________________________________________________________

Social history:Married______ Divorced _______ Any relationship

stressors__________________________ Do you have children?: ___________ If yes,
number of children: ___________
Significant physical traumas (auto accidents, etc.):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Surgeries, including cosmetic, with dates:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please circle any current areas of pain, discomfort, or displeasure on the following

diagrams:

Facial area:

HABITS:Cigarettes______________(packsperday)coffeeTeaCola
Alcohol__________(numberofglassesorbottlesperweek)RecreationalDrugsSweets
SaltOther:____________________________
DENTALHISTORY:Please list number of cavities, surgeries, significant trauma, etc.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FAMILYHISTORY:Pleasecircleifanimmediatefamilymember(mother,father,
brother,sister,aunt,uncle,grandmother,grandfather,orchild)hasoneofthefollowing
conditions:Cancer____________________(type)Diabetes(TypeIorII)Highblood
pressureHeartdiseaseHighcholesterolStrokeSeizuresAsthmaAllergies
AlcoholismMentalillnessArthritisInheritedblooddisorderAutoimmunedisorder
Other:__________________________________________________________________.
DIET:
Please list a typical day and any food restrictions or food sensitivities
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
EXERCISE:
Please list physical activities and the number of times per week you do them
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What would you like to change about your health and/or life?:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________