Intake - Acupuncture Ajax

New Client Intake Form

Thank you for booking your session.
Please complete this short intake form before your appointment.

Your information is confidential and used solely for scheduling, documentation, and clinic reporting purposes under OHIP guidelines.

If you have any questions before your visit, please don’t hesitate to contact the clinic.

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Date of Birth(Required)

OHIP Number

If you are uncomfortable submitting your OHIP number in the online form, just bring it with you to your first session at the clinic.

OHIP Expiry Date

Referral Source(Required)

Primary Reason for Visit

Consent Checkbox(Required)

I understand this information is confidential and used for booking and clinical documentation only.