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Forms

When planning your consultation, it is recommended that you print and fill out the following patient information forms prior to your visit. Forms are in PDF Format. Just print the forms and fill in the required information. If you do not have Adobe Reader, download it here.

For ALL New Acupuncture Patients

  • Registration Form
  • HIPAA Notice of Privacy Practice (For your record only. You do not have to bring it with you.)
  • Consent Form
  • Arbitration Agreement Form

For New Acupuncture Patients

  • Health Questionnaire for regular acupuncture treatment

For New Meizen Facial Cosmetic Acupuncture Patients

  • Meizen Facial Cosmetic Acupuncture Consent Form
  • Meizen Facial Cosmetic Acupuncture Intake Form

Kimura Acupuncture, P.C.
99 Hillside Ave., Ste. K
Williston Park, NY 11596
(516) 882-1292
Serving Williston Park, Mineola, East Williston, Roslyn Heights, Roslyn, New Hyde Park area.

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