Lemon Grove Acupuncture
New Patient

Patient Intake Form

Please fill out your information below before your first visit. We'll use this to verify your insurance benefits so there are no surprises on the day of your appointment.

Personal Information

Contact & Preferences

Provide at least one — phone or email.

Insurance Information

Insurance Card Photos

Optional but recommended — speeds up verification

Front of Card

Back of Card

Your information is transmitted securely and used only for insurance verification purposes.

Questions or Comments

Optional — anything you'd like us to know before your visit

Fields marked * are required.