Online Forms

To help make your first visit to our practice as smooth as possible, please read the information on this web page. You'll find all the practical information you need, such as a map and directions to our office(s), practice hours , payment policies and more. We also describe our first visit procedures. And, you can save some time by printing out and completing the new patient forms in advance of your appointment

Mission Statement

Our practice is working together to realize a shared vision of uncompromising excellence in medical care.

To fulfill this mission, we are committed to:

- Listening to those we are privileged to serve.
- Earn the trust and respect of patients, profession and community.
- Exceed your expectations.
- Ensure a creative, challenging and compassionate professional environment.
- Strive for continuous improvement at all levels.

Pure Acupuncture & Natural Medicine offers patient form(s) online so you can complete them in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

Financial Policies

New Patients Acupuncture Forms

Acupuncture New Patient Form
Office Policy and Doctor Lien
Patient HIPAA Questionnaire
Notice of Privacy Practices
General Consent & Records Release Form
Fertility Questionairre
New Patient Fertility Form - Men and Women

Facial Acupuncture - MeiZen Forms

MeiZen Welcome Letter
MeiZen Facial Acupuncture Consent to Treat Form
MeiZen Photographic Consent Form

Nutritional and Herbal Forms

Symptom Survey Form
Consent for Intramuscular Vitamin + Trigger Point Injection
Weight Loss Questionnaire

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Lake Mary Location

Office Hours

Lake Mary Location


10:00 am-1:00 pm

3:00 pm-6:30 pm


3:00 pm-7:00 pm


10:00 am-1:00 pm

3:00 pm-6:00 pm




10:00 am-1:00 pm

3:00 pm-6:00 pm