Acupuncture Home Visit Form

Thank you for scheduling a home visit treatment with me. Could you please complete this form at your earliest convenience. This will ensure that I am fully prepared to provide you with the services and products you may require on the day.

Name

Phone

Address

1. Why have you made your booking with Dr. Bree?

Postpartum Care
Induction
IVF Transfer
Back Pain
Headaches
Other

2. Are you currently having regular acupuncture treatments?

3. Which services are you hoping to receive? *

Acupuncture
Moxibustion
Herbal Treatment
Oils, teas, linements
Dietary Recommendations
Ayurvedic Postpartum Doula
Other

Answers are used to provide Dr. Bree with insight into your expectations for the treatment. However, she will develop a personalized treatment plan based on her assessment of your needs.

4. Do you give Dr. Bree permission to call you before your treatment if she has any questions?

I consent to Bree Bennetts visiting my home for treatment. I understand that acupuncture may occasionally cause minor bruising marks, and cupping may leave marks lasting 2-3 weeks. I recognize that Bree has the discretion to determine if I should receive herbs or any particular treatments based on her professional expertise.

Thank you for filling out this form. If you have any additional information you would like to share with Dr. Bree in advance or if you have any questions, feel free to email her at hello@drbreetcm.com.

Thank you!

Thank you for taking the time to complete the consent form, I look forward to speaking with you soon.

Thank you!

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