top of page
Log In
StoonRMT
Meet Our Team
Locations
22nd Street -StoonRMT
Primrose Drive - StoonRMT
About Stoon RMT
About Dr. Xin Zhong
Massage Therapists
SGI & WCB Claims
Book Online
Intake Form
Acupunture Intake Form
Cupping Treatment Form
Direct Billing Form
Services
Carpal Tunnel Treatment
Cranio Sacral Therapy
Deep Tissue Massage
Hot Stone & Jade Therapy
Integrative Women's Health
Lymphatic Drainage
MyoFascial Release
Plantar Fasciitis
Prenatal & Postnatal Massage
RAPID Neurofascial Reset
Relaxation Massage
Scar Tissue Release
Sciatica Treatment
Subsidized Massage Therapy
TMJ Treatment
Acupuncture
Cupping Therapy
Dry Needling Electro Therapy
MicroNeedling
Moxibustion
Birth Support
Elemental Self Series
Primal Regeneration
Hibernation Retreat
Closing The Bones
Nourished Parenthood
Postpartum Care
Innate Postpartum
Move Through Birth
Period Class
Shapeshift Class
WombCare
Contact
Blog
More
Use tab to navigate through the menu items.
Acupuncture Intake Form
If this is your first time booking in with us or haven't been to the clinic in over a year, please fill out the information below
First Name
Last Name
Perferred Name
Cellphone
Email
What is your Date of Birth
Have you tried acupuncture before?
*
Required
Yes
No
Primary reason for visit? When did the problem begin?
Select an option for your Gender
*
Male
Female
Other
Do any of the following help you with pain?
*
Required
Heating pad
Ice pack
Rest only
other
NONE OF THE ABOVE
Select from the following to describe your bowel movements
*
Required
Regular 1-2 times per day
Constipated once evrery 2-3 days
Chronic Diarrheic 2-5 times a day but loose
Do any of the following make your pain worse
*
Required
Activity
Anger
Stress
Anxiety
Weather change
Menstration
NONE OF THE ABOVE
How are you sleeping at night?
*
Required
Good 6+ hours
wake up easily or often
Stays in a deep sleep all night
Has a hard time going to sleep
What is your occupation? cause stress or tension?
I consent to allowing my therapist/ receptionist to sumbit Direct Billing on my behalf
if you have and want to you can add your direct billing information below, it will attach to your file for future reference
Date of injury:
SGI/WCB Claim Number:
Health Card #: (Only for WCB/SGI claims)
Continue
bottom of page
