For first time patients -

Before we begin your treatment, you are required to download the applicable forms below and fill them out before your visit.

※Adobe Reader is required to access our patient intake form. if you do not have Adobe Reader, you can download it by clicking the logo below. (Adobe Reader is free)

 

Adobe Readerのダウンロード

 

If you have any trouble downloading and printing our forms, they are also available at our office. You may either pick them up, or contact us by phone or email if you would like them mailed to you, or fill them out at our office before your first visit.

 

 
Downloadable Forms

Complete set of forms for general patients  Click Here
Patient Information
Medical History
Health History

Complete set of forms for Infertlity Treatment (Women)  Click Here
Patient Information
Medical History
Health History
Women's Fertility History


Form for Male Infertility Click Here
Men's Fertility History
Please also download this which includes the forms below Click Here
Patient Information
Medical History
Health History

 

 

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RESERVATION

INQUIRY

Areas of Expertise

fertility treatment

美容鍼灸 Haristiqe LE ACURA

アキュラ鍼灸院院長の著書紹介