Pacific Wellness Institute Clinic: Bloor-Yorkville Toronto

Pacific Wellness Consultation Forms



* Please review our Website Privacy Policy and The Pacific Wellness Institute Privacy Code.

New Patient Form – Acupuncture

Fill out and submit the form online via secure internet connection.

Alternately, the completed form can be faxed to: 416-929-6365.

*It is important that you provide your accurate email address and reachable phone numbers so that we can contact you promptly.

Acupuncture Secure Online Form

Acupuncture form (PDF)

New Patient Form – Massage, Shiatsu, Reflexology

Please bring the completed form with you at your first visit.  The form can also be faxed to: 416-929-6365.

Massage form (PDF)

Supplemental Forms

Kampo Constitutional Evaluation Form Online SSL Kampo Form