Forms and Notes

087 624 9555

Forms and Notes

087 624 9555

~ Below are resources available for current clients of Well Being Dublin Acupuncture, Herbal Medicine and Naturopathy clinic ~

Forms and or notes for workshops will be added beforehand and be available for download for two weeks to attendants. If any questions or concerns about accessing these forms before your treatment, please phone Anne at 087 624 9555 or email her at [email protected].

PLEASE NOTE: Before your initial visit, please be sure to print and complete the appropriate form.

If you wish to use the fillable form feature, you will need to click on the link and save the form to your computer (do not fill it out online).  Once you are done filling out the form, please be sure to either save it or print it to PDF if you wish to save a copy, or just print it out.

The form DOES NOT automatically save entered information once you close it. You may also just print out the form and fill it out by hand.

If you wish to email the completed form to our office, please email it to [email protected].

For patients returning to the office, if it has been more than *3 years*, or if you have had any *recent significant and complex medical changes* we should be aware of, please complete the new medical form below prior to your next appointment.

New Patient Intake: This form collects Anne’s patient’s basic information (full name, address, email, phone) as well a thorough health history, including if relevant, current and past symptoms. The forms are arrange by systems (cardiovascular, digestive, etc.).


Informed Consent for Acupuncture: This is required by nearly all insurance purposes.


Release Form: For any patient who is under the age of 18. It’s essentially an informed consent for treatment that the patient’s parent must sign.


Notice of Privacy Policies: This form explains to clients that their health information is confidential except in specific situations, explains that they have a right to their information and how they can obtain it, and has a place for them to acknowledge and sign. Should be HIPAA compliant.

The European Union law GDPR (General Data Protection Regulation) forms which are required for storage for 5 years by your practitioner pertains to how Well Being Dublin handles and stores you data.

13+ Years
in Practice
Irish Based
Knowledgeable, Caring & Results-driven