Acupuncture, Herbs, & Supplements since 1982
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Forms

Below are some blank forms that you might find useful. All are in PDF format.

Important Information and Disclosures for Patients of Michael Broffman, LAc
Prior to your appointment with Michael Broffman, LAc, please sign and return a copy of this disclosure form.

Patient Medical Record Request
If your doctor requires a letter from you to release records to us, you can use this template.

Food Diary
Use this form to record everything you’ve eaten for an entire week.

Current Medications, Vitamins, & Supplements
Use this form to list all the medications, vitamins, and supplements you’re currently taking. Note that this form is different from the home inventory list (below).

Home Inventory of Herbs & Supplements
Use this form to list all of the herbs and supplements you physically have in your home inventory.

Authorization for Release of Protected Health Information
Use this form to authorize your doctor and other health care practitioners to share your health information with others.