Patient Forms

Help us to help you! Use this page to download the Health History and Consent forms that will need to be filled out on your first visit to the Somerville Health Associates clinic. Simply click on the links for each, print them out, and bring the completed forms when you come in.

To open and print these forms you will need Acrobat Reader.

New Patient Forms
New Patient Health History
Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations
Acupuncture Consent to Treatment

New Patient Fertility (Male)
New Patient Health History
Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations
Acknowledgment of Informed Consent and Authorization (Fertility Treatments)
Men's Fertility History

New Patient Fertility (Female)
New Patient Health History
Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations
Acknowledgment of Informed Consent and Authorization (Fertility Treatments)
Women's Fertility Treatment History
Basal Body Temperature (BBT) Chart

Privacy Practices
Notice of Privacy Practices


Learn more about how Acupuncture can help with... Pain Infertility Menopause Allergies IBS Depression Fibromyalgia Facial Rejuvenation Quitting Smoking



Acupuncture Wellness
1798A Mass Ave
Cambridge, MA 02140
Phone 617.448-9440
info@debrawood.com

©2014