Healing Hands
518 Main street
Bethlehem, PA 18018
www.healinghands.com
SERVICES PROVIDED:
Facial Rejuvenation Acupuncture.
$160 one hour appointment.
12 sessions for the series.
Maintenance: Monthly or seasonally, & as needed.
Nutritional consultation/Naturopathy.
First visit $220 one hour appointment.
Return visits $110 for 30-45 minute followup.
Group Acupuncture sessions.
$50 for a half hour session with up to 3 people in a group setting.
Private Acupuncture sessions.
First visit $180 one hour appointment.
Return visits $90 45-60 minute visits.
Appointments made through Healing Hands. Visits are not covered by
insurance.
Cancellation policy: Missed appointments will be charged unless notified of
changes within 24 hours of visit.
Please fill out this form prior to your first visit and
bring it to your practitioner.
Thank you.
diagrams:
Facial area:
HABITS:Cigarettes______________(packsperday)coffeeTeaCola
Alcohol__________(numberofglassesorbottlesperweek)RecreationalDrugsSweets
SaltOther:____________________________
DENTALHISTORY:Please list number of cavities, surgeries, significant trauma, etc.
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FAMILYHISTORY:Pleasecircleifanimmediatefamilymember(mother,father,
brother,sister,aunt,uncle,grandmother,grandfather,orchild)hasoneofthefollowing
conditions:Cancer____________________(type)Diabetes(TypeIorII)Highblood
pressureHeartdiseaseHighcholesterolStrokeSeizuresAsthmaAllergies
AlcoholismMentalillnessArthritisInheritedblooddisorderAutoimmunedisorder
Other:__________________________________________________________________.
DIET:
Please list a typical day and any food restrictions or food sensitivities
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EXERCISE:
Please list physical activities and the number of times per week you do them
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What would you like to change about your health and/or life?:
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