FORMS

For first time acupuncture, herbal, or Asian bodywork patients, please fill out the following forms before you arrive for your first appointment to make the most of the time available. (Chiropractic and Reflexology patients fill out different forms at arrival)

	Fertility Questionnaire Form
	Informed Consent Form
	Intake Form
	New Patient Form
	Payment Guidelines
	HIPAA & Your Privacy Rights

SOURCE HEALING
650 N. Dearborn St. - Suite 800
Chicago, IL 60610

PHONE: 312-335-9330
FAX: 312-264-0398

EMAIL: info@sourcehealing.com