NEW PATIENT INFORMATION FORM

Basic Information
Medical Information

Please fill in carefully. It is very important for the TCM doctor to fully understand your current situation. 请务必认真填写。让医生全面了解你的现状，对治疗是非常重要的。

I understand by signing and submitting this form that the information provided is true to the best of my knowledge. I will advise this clinic of any changes to the above details during future visits.
我明白，通过签署并提交此表格，我所提供的信息在我所知范围内均为真实准确。如有任何上述信息的变更，我将在日后就诊时告知本诊所。

Copyright by TCM Dr. Ma

Warning: this note contains the personal information subject to privacy protection, unauthorized reading is prohibited.