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Office Forms


To streamline your first visit, please download and fill out all five forms below.  You may complete these electronically and email them (, print and complete by hand then send pictures by email or text (270-559-5906), or bring completed paperwork along to your appointment. Of course, printed copies (and a disinfected pen) are also available at the clinic. Thank you!



Complete this form before EACH appointment and email, text, or bring with you. 

Normal Operating Procedures (always in place)

  • An acupuncturist’s treatment location should be kept clean and sanitary with an appropriate schedule for cleaning and decontamination. 

  • A sink with hot and cold running water must be located in or near the treatment rooms. Liquid hand soap and paper towels must be available at hand washing stations. Alcohol-based hand sanitizers may also be available.

  • Any paper or other disposable material used as a covering on a chair, seat, or treatment table, should not have been previously used in connection with any other patient. Any towel, cloth, sheet, gown, or other article that contacts the patient’s skin should be clean.

  • The treatment room table tops, shelves and other working surfaces should have a smooth, impervious surface, be in good repair, and be cleaned with a suitable disinfectant at least once a day and whenever visibly contaminated or whenever a patient may have contaminated the surface by coming in contact with the surface directly. 

  • Treatment tables and chairs used for treatments need to be cleaned and reset between each patient visit.

  •  Reusable medical and AOM (Acupuncture & Oriental Medicine) equipment must be disinfected between use on patients per CDC (Centers for Disease Control & Prevention) guidelines.

  • All needles are sterile, single use and disposed of after treatment per CNT (Clean Needle Technique) requirements.

COVID-19 Policies & Procedures

Illness Policy: stay home if you are sick.

  • In the 24-48 hours before you come for your appointment, I’ll ask you screening questions about potential symptoms and exposure to COVID-19. If you have had these symptoms (fever or chills, cough, shortness of breath, fatigue, body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) in the past 48 hours or exposure to someone who has, you will be asked to delay treatment.

  • If you think you could have been exposed to COVID-19 and have not received a negative test result, do not come in. 

High risk categories:

The high risk categories for COVID-19 include people over the age of 60 and people with underlying chronic health conditions, such as heart disease, kidney disease, cancer, or diabetes. If you or someone in your household falls into any of these categories, you should strictly limit your contact with other people and stay home when possible.


COVID-19 Safety Procedures:

Five Elephants Acupuncture is closely following CDC guidelines for healthcare facilities pertaining to hand hygiene, cleaning, disinfecting, and social distancing. 


  • You’ll be asked to sign a COVID-19 Informed Consent (located above) of agreement with the new policies that are in place before your first appointment back and complete a COVID-19 Screening (also located above) for symptoms/exposure before each appointment.

  • Payment options:

    • Best: PayPal (

    • Good: Cash (exact change, please) or check 

    • Okay: Credit/debit/HSA/FSA card over the phone


  • Wait in your car and call me instead of coming to the clinic door right away. We will chat about your needs and the treatment plan before you enter, keeping our conversation to the minimum once you are inside. 

  • The waiting area is closed so, unless you require a caregiver, please ask anyone accompanying you to your appointment to wait outside of the building. 

  • After our check-in call, you’ll come to the door and I’ll meet you outside with my cool new digital thermometer. 

  • Everyone is required to wear a mask that covers the nose and mouth inside the clinic at all times. Let me know if you need help finding/making one! Please be wearing your mask when I step outside. 


  • We will maintain the recommended 6-feet social distance buffer, aside from when I am actually providing treatment. 

  • You will be asked to wash your hands with soap and water or use hand sanitizer.

  • After washing hands, you’ll go straight to your treatment area to remove shoes (just when we all got used to leaving them at the door!) and settle in for treatment.

  • Cloth coverings and unnecessary items have been removed from treatment areas and we will be using a space heater instead of space blankets to keep you cozy. Bring a layer if you think you might want one. 

  • For now, treatment will be streamlined to acupuncture and, only if it’s needed, one accessory technique (cups, e-stim, moxa, but no gua sha at this time). 

  • Treatment time will be limited to 30-45 minutes in order to allow time for cleaning between patients. 


  • You will be asked to wash your hands (or sanitize) once again.

  • Enjoy! Take it a little easy and drink plenty of water. No changes there, just a good reminder.


Additional Precautions:

  • Anyone who enters the clinic will be asked to monitor their health, follow all CDC recommendations for social distancing, and complete COVID-19 screening before entry each time.

  • High-touch surfaces will be sanitized multiple times per day and between each appointment.

  • I am suspending use of glass cups and will be using disposable (but still recyclable!) for now.

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