Patient Intake Form
The form is quite detailed so give yourself around half hour to complete it. With traditional Chinese medicine every aspect of your health and lifestyle is important to the practitioner, as they follow a holistic approach to treatment and everything ties together to form a complete picture of health.

 All information provided will be kept strictly confidential. It is used solely for analyzing your body physique in details by the practitioner in order to best help you customize the most suitable treatment plan.

Please call or text on 020 4014 2280 if you have any trouble with the form. Alternatively, you can reply to this email for assistance. Thank you for your patience.

Our address is 16A Taniwha Street Frankton. At the end of cul-de-sacs , turn right into a concrete driveway, at the end of the driveway on the right side you will see Jing Acupuncture. There is parking in front of the clinic.
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COVID-19 Patient Screening Questionnaire
To ensure we operate in a safe environment whilst we deliver the diagnostic and treatment interventions you need, we will be performing screening questions to all our patients related to COVID-19.  

If you answered YES to a number of questions, we may contact you and ask you to reschedule appointment at a later time.  

To ensure the ongoing health and safety of our patients and staff, please complete the following declaration before checking in for your acupuncture treatment.

Thank you for your cooperation and understanding.
Do you have a FEVER > 38 degrees? *
Do you have one or more of the following NEW symptoms ( New - within the last 4 days)? *
Required
If you answered YES to a number of questions, we may contact you to reschedule an appointment for you at a later time.
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