Acupuncture Intake Form — shared by the community
Tom H. shared this 25-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 25 questions, 3 pages, 3 conditional rules.
- Shared by
- Tom H. · Agency owner
- Questions
- 25
- Replies
- 4
- Copies taken
- 641
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Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 3 — Your first consultation
This template runs as a straight sequence — no branching rules.
Works for you? Take Tom H.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Acupuncture Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 25 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 11 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Acupuncture Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “Have you received acupuncture before?” is Yes, “Previous acupuncture experience” becomes mandatory before the form can be sent.
- Features conditional validation: if “Any bleeding concerns or blood-thinning medication?” is Yes, “Bleeding concerns to review” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you have an implanted electronic device?” is Yes, “Device information for the practitioner” becomes mandatory before the form can be sent.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Your first consultation
- Full namerequired
- Email addressrequired
- Phone number
- Date of birthrequired
- Emergency contact name and relationship
- Emergency contact phone
- Main concern and how long it has been presentrequired
- How this affects your daily activities
- Have you received acupuncture before?required
- Previous acupuncture experience
Page 2 — Health context
- Current diagnoses, medications and supplements
- Allergies and sensitivities
- Any bleeding concerns or blood-thinning medication?required
- Bleeding concerns to review
- Do you have an implanted electronic device?required
- Device information for the practitioner
- Pregnancy-related information you want the practitioner to consider
- Sleep, energy and other priorities
Page 3 — Visit preferences and acknowledgment
- Preferred consultation date
- Preferred time of day
- Would you like fee information before booking?required
- Communication or accessibility preferences
- Intake acknowledgmentrequired
- Patient signaturerequired
- Date completedrequired
Conditional logic in this build
- When “Have you received acupuncture before?” is Yes, require “Previous acupuncture experience”.
- When “Any bleeding concerns or blood-thinning medication?” is Yes, require “Bleeding concerns to review”.
- When “Do you have an implanted electronic device?” is Yes, require “Device information for the practitioner”.
Questions about this shared form
Is this informed consent for acupuncture?
No. The acknowledgment covers intake only; the practitioner must explain any proposed procedure and obtain appropriate consent separately.
Can a patient avoid typing sensitive details?
Yes. Keep the private-discussion options and provide a suitable contact channel before the appointment.
How does it differ from Patient Intake Form?
Patient Intake Form handles general registration; this version emphasizes acupuncture experience and concerns relevant to the consultation.
Does submitting a preferred date reserve a visit?
No. Coordinate availability separately, using Appointment Request Form if you want a dedicated scheduling request.
Is the Acupuncture Intake Form template free to use?
Yes. You can preview and test Acupuncture Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Acupuncture Intake Form template ask for?
It asks 25 questions across 3 pages, 11 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Acupuncture Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Have you received acupuncture before?” is Yes, “Previous acupuncture experience” becomes mandatory before the form can be sent. Features conditional validation: if “Any bleeding concerns or blood-thinning medication?” is Yes, “Bleeding concerns to review” becomes mandatory before the form can be sent. Features conditional validation: if “Do you have an implanted electronic device?” is Yes, “Device information for the practitioner” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Acupuncture Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Acupuncture Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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