Patient Intake Form

Welcome to Bernadette Yu Wellness! Are you an EXISTING or NEW patient?

Existing

New

Primary Health Concerns

Purpose Of Visit:

Assessment Plus Acupuncture

Assessment Plus Chinese Herbal Medicine

Facial Acupuncture

Assessment Plus Guasha and dry cupping

Nutritional Consultation / Bioenergetic Test

Bioenergetic Food Compatibility Test

Healthy Pregnancy Preparation Session

Cancer Recovery Planning Session

Where did you hear about us?

Please List Any Medication You Are Taking

Name of prescribed medication

Surgery History

Current health habits and symtoms:

Please write down the "ONE THING" that matters to you the most and which can be achieved / improved by fixing your Primary Health Issue.

Interested to know which supplements and foods can address your health issues? Tick here for practical advice during your appointment. Additional fees: $80 + tax (may be covered by insurance under "Holistic Nutrition").

Yes, I would like to receive supplement and diet advice. I understand a fee of $80 + tax will apply to this additional service.

If interested in receiving a Chinese herbal medicine prescription during your acupuncture session, tick the box. A fee of $35 + tax applies, excluding the cost of the herbs. Orders can be placed separately at Cost + shipping + administration fee and relevant taxes. Your visiting fee may be covered by your insurance health-care spending account.

Yes, I would like to receive Chinese Herbal Medicine Prescription. I understand a fee of $35 + tax will apply to this additional service.

Terms and Conditions

I acknowledge the effectiveness of Acupuncture, Chinese Herbal Medicine, dietary/nutritional therapy, and other TCM methods for preventing and treating various health issues and enhancing overall well-being. While beneficial for many conditions, I understand these treatments do not substitute any medical tests or therapies advised by my physicians. I will maintain my prescribed medications alongside any alternative treatments received at this clinic.

I've shared my health details and medications with the TCM Practitioner/Acupuncturist/Registered Nutritionist and will keep them informed of any changes. The practitioner isn't liable for omissions in information. I recognize no guarantees are given, and the effectiveness of treatments can be influenced by medications and lifestyle. I take full responsibility for my treatment outcomes.

I acknowledge that Acupuncture and related TCM practices are generally safe. Bruising from needle insertion is normal, while fainting is rare but can occur due to extreme nervousness, hunger, or fatigue. Needling sensitive points below the waist or near the breasts may be required, and verbal permission will be sought.

Herbal medicines are usually safe and effective, although some may experience occasional side effects like abdominal upset, diarrhea, or sweating in response to treatment.

Clinic Fees & Policies

Fees for initial appointments with an assessment, diagnosis and treatment are as follows:

Acupuncture with cupping or TCM Tuina Massage: $135
Guasha (Scraping) appointment: $135
Facial Acupuncture: $155
Bioenergetic Test: $180 + tax
Food Compatibility Test, Pregnancy Success Preparation Session, or Cancer Recovery Planning Session: $250 + tax each
Chinese Herbal Medicine consultation: $80 + tax (initial appointment). Chinese herbs can be purchased at cost, with additional charges for shipping and administration. Herbal medicine refills incur a $10 administration fee plus tax.
Nutritional guidance request during your acupuncture appointment, with personalized supplement and dietary recommendations provided via text or email: an additional $80 + tax,

Please be punctual for all scheduled appointments. If you arrive late and cannot receive services due to time constraints, and your spot could be taken by another patient, a $50 fee will be added to your next visit, unless a medical emergency caused the delay.

You consent to the practitioner(s) review, analyze and store your submitted information. The practitioner(s) can respond to your input or provide feedback, advise by either email, phone or text messages.

First Name

Last Name

Phone Number

Emergency Contact's First Name

Emergency Contact's Last Name

Emergency Contact's Phone Number

Date of Submission

Signature of Patient

Sign Here

Patient intake form

Terms and Conditions

Clinic Fees & Policies