Patient Forms

    Patient Medical History

    Chief Complaint

    Secondary Complaint

    System Review


    • Patient Medical History


    • Chief Complaint


    • Secondary Complaint


    • System Review


    • Signature

      The scope of Acupuncture in the state of Florida and the modalities used at this clinic includes but is not limited to:

      • Use of acupuncture needles to stimulate acupuncture points.

      • Moxibustion – a herb placed on acupuncture needles to stimulate blood flow.

      • Laser Therapy – K Laser or Class IV Laser therapy is used to stimulate endorphin release, manage pain, and increase healing potential to injuries.

      • Micro-Current or electroacupuncture is applied to acupuncture needles which increases endomorphin, a natural opioid pain killer.

      • Fire Cupping - suction cups are applied to areas of the body to alleviate tight muscles and to improve blood flow and circulation.

      • Gua Sha or Dermal Friction Technique is used on the skin to stimulate blood flow and microcirculation of soft tissue.

      • Chinese Herbal Medicine/Homeopathic Medicine/Nutrition

      • Bodywork/Tui Na/Shiatsu/Trigger Point Therapy/Cranio-Sacral Therapy

      • Injection Therapy (homeopathic, Vitamin B-12)

      Possible Side Effects:

      • Minor bleeding or bruising may occur as a result of acupuncture, cupping and related therapies.

      Please check any items that apply to you:


      To Continue
      Check Box below in Red.
      Press “Proceed to Signature” at bottom of page.

      Next Page
      Scroll to bottom of page and click on “Sign Here”
      Click “Draw” or “Type” Signature
      Click “Adopt & Sign”
      Lastly, “Agree & Sign”

      This document will be sent to us electronically. No need to print unless for your own records.

      I release Dr. Tony Willcox PhD. and Acupuncture Zen Inc and its staff from any all claims incurred to me as a result of treatment. I understand that no statement made is intended as a medical diagnosis, nor is it considered as such. There is a no refund policy on all goods and services sold including oils, patches, herbal medicines, treatments, gift cards and packages at Acupuncture Zen Inc. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment. I confirm that I have read and understand the above information.


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