QIN ACUPUNCTURE & CHIROPRACTIC CLINIC 855 E. Palatine Rd. Ste. 170 • Palatine, IL 60074-5500 • Phone: (847) 202-9988 • Fax: (847) 202-9795

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Contact Information Our Clinic is Located at: 855 E. Palatine Rd. Ste. 170 Palatine, IL 60074-5500 Office phone: (847)202-9988 Office fax: (847) 202-9795 Email: qinacupuncture@yahoo.com Website: www.qinacupuncture.com Your first appointment... If you have insurance, please remember to bring your insurance card. You will be asked to fill out a four page patient registration form. You may do that ahead of time by downloading and printing the following documents. Please fill out all four pages completely to the best of your knowledge. Page 1 Page 2 Page 3 Page 4