Patient Intake Form

  • Patient Information and Contact Details

  • Health and Medical History

  • Please check the appropriate box for any diseases or conditions:

  • Female History

  • Menstrual cycle
  • Pregnancy History:
  • Ovulation
  • Menopausal symptoms:
  • Male History

  • Patient Acceptance

  • Cancellation Policy:
    Ondol Oriental Medicine Clinic applies a 24 hour cancellation policy. We ask clients to respectfully give 24 hours’ notice if an appointment needs to be cancelled or rescheduled. This allows time to fill the appointment with another person. The full consultation free will be charged if notice is not given.
  • Client confidentiality:
    Ondol Oriental Medicine Clinic respects and adheres to client confidentiality and privacy. The information provided on this form and to the practitioner will remain strictly confidential.

    By signing below, you acknowledge and accept both policies outlined on this form, and confirm that the information you have provided is correct.