206.388.5881 melissa@blackpinehealing.com

New Patient Forms

New patient forms

Wherever there is a Word document here, it is a fillable form; hopefully it should make completing any of these faster. Feel free to email back forms using an electronic signature, or if you do not have an electronic signature, the pages that do not require a signature. Thank you in advance!


(for you)

These forms are to be reviewed before treatment (no need to print or sign); when you consent to treatment you acknowledge you have received and reviewed these documents.

Adobe .pdf

Intake Forms

(for Melissa)

These forms are to be filled out before treatment; you can either email them back to Melissa before your first visit, or you can simply bring the completed forms with you to your appointment.

Prepare for Treatment

(for you)

To get the most benefit out of your treatment, consider following these few guidelines and precautions for before and after session. (No need to print or sign.)


Adobe .pdf

Insurance Verification

(for acupuncture)

Before you seek reimbursement for acupuncture services, know what questions you should ask of your insurance company.

Health Information Release

(for third-parties)

This release form is for those patients who are newly-referred to my services, relocating, and/or who recently expanded their healthcare team; signing this form authorizes me to discuss your case with your other providers, ensuring you receive the most complete, coordinated care.

HIPAA privacy regulations stipulate that health care providers may not use or disclose a patient's health information without his or her authorization, except as described in the Notice of Privacy Practices. That document clarifies the conditions under which a patient's information may be released without his or her authorization, and when an express authorization is required by the patient.

Under certain circumstances, it may become necessary for this office to release a patient's health information to an individual or entity outside of this office. In accordance with the Notice of Privacy Practices, this office, via this authorization form, requests that the patient indicated below authorize the release of his/her health information.

File a Complaint

HIPAA Privacy

If you believe your or someone else's health information privacy rights were violated, or that another violation of the Privacy Rule occurred by Melissa Dana/Black Pine Holistic Healing, please submit this complaint form for further investigation.


If you have concerns about the health care or treatment that you or a family member received or did not receive, please submit this form. *You may submit an anonymous complaint.*