Intake Forms

Willow Tree Wellness Clinic's Intake Forms (PDF)   Please fill out before your appointment and bring with you.  There are a lot of questions that may not seem related to your condition but will provide useful insight leading to your proper diagnosis.  We want you have time to think about the questions without cutting into your treatment time. Grab a cup of tea and give yourself about 15 minutes to consider how you have been feeling.

Acupuncture Insurance Billing Info

Finances:

We bill most major insurance companies directly as a courtesy to our patients. Please visit our insurance billing page to see our list of companies that we are contracted with as In Network providers. We are required to collect co-payments, remaining deductible balances and co-insurance at the time of each appointment. If you do not have acupuncture benefits, we offer a time of service rate and a Superbill with diagnosis and procedures codes that can be applied to your annual medical expenses deduction.

Motor Vehicle Accidents:

In Oregon, acupuncture is a covered medical expense through your Personal Injury Protection (PIP) policy. We are required to carry a minimum of $15,000 in medical care coverage per person that is applied to any medical care you need as a result of an injury caused by a car accident. There is no out of pocket expense to you, so please take care of yourself and seek the care that you need. The sooner you get started, the easier and more quickly we will get you out of pain and back in top form!

Cancellations:

Please note that your appointment times are reserved especially for you, and that 24 hours notice is required for any cancellation or changes. Because we are all human, each person will have one ‘forgiven’ missed appointment.  After that, all missed appointments will incur a $50 cancellation fee.

Thank you.  We look forward to working with you!