John Aguilar, Jr., L.Ac., R.Y.T., M.S.TCM

Licensed AcupuncturistChinese Medical HerbalistYoga and Tai Chi Instructor


New Patients

Below are the forms and paperwork I use during the initial session. Please feel free to download and review them or even print them out and bring them in completed.

Patient Information Form

Personal information such as name, address, etc., as well as medical information and history.   

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Policies Form

A short review of standard office and practice policies, such as cancellation fees, right to discontinue treatment, and so on. 

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Mandatory Disclosure Form

Information required by Co state law to be disclosed at the initial treatment session, including information on my license, training, professional degree, and board certifications.

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HIPPA Notice of Privacy Practices

This packet describes how medical information about you may be used and disclosed and how you can get access to this information.

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Acknowledgment of Receipt

This is a simple form you sign as indication that you recieved a copy of the above 'Notice of Privacy Practices'. 

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Please note: The following forms are offered, here, for your review only. You will need to sign original copies at the office.

Informed Consent

This form covers the nature of acupuncture and herbal medicine and talks about potential side effects.

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Arbitration Agreement

By both of us signing the 'Arbitration Agreement', we agree to use a private, confidential, and expedited arbitration, rather than a lengthy and costly courtroom trial, to settle any potential disputes. (In arbitration, a neutral arbitrator, often a retired judge, decides the case.)

This agreement is required by my insurance carrier. Such forms are being used throughout the healthcare industry to keep the cost of insurance down.

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*You'll need the Adobe Reader to read the PDFs. You can download the latest version here.

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