New Patient Forms

Congratulations! You have just taken the first step to better health. Please download our New Patient Forms below, fill them out and bring them to your first appointment. This will allow us to focus the entire first session on getting to know you and your history, not on paperwork. If you are unable to fill out the forms at home, you may request that we e-mail them to you or ask us to leave them for you at the front desk on the day of your first visit. It will take you about 20 minutes to fill out the forms in our office, so please plan accordingly.

Important:  Treatment cannot begin until all of your forms are received and signed.

New Patient Forms 2013

Fertility Testing and Treatment History(fertility patients only)

If you have to change your first appointment for any reason, please give us 24 hours notice so that we can give that appointment to a patient on our waiting list.

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    Breast Cancer

    On August 26,2014 I was diagnosed with stage III Triple Negative and Inflammatory breast cancer at 39 years old. Due to the aggressive nature of the two types of BC I was diagnosed with, I was started on an intense regime of 4 different chemotherapies starting August 29, 2014. The weeks after the first dose of chemo were quite possibly the most sick I have ever felt in my life. Luckily I was very healthy to start, because I believe it could have been much much worse. My sister had recently begun to see an Acupuncturist and found that this was helping her a great deal. The Acupuncturist from Connecticut suggested Julie Permut to help with my severe side effects. Though they did not know each other, the Acupuncturist felt Julie’s credentials were the best in the area. A bonus was that Julie practiced 2 minutes from my front door in Peterborough NH! Since I was receiving treatment at Dana Farber in Boston, this was a welcome stroke of luck. I first saw Julie about 2 weeks into treatment. Just before my very long dark curly hair started coming out in large tufts in my hands. I was weak, shaky, nauseous, lethargic and completely terrified of what lay ahead. I wish I could say I was one of those people who tell you, “well I’ve had a good life so…. or I am going to kick cancer’s butt!!!.” But that wasn’t me. I knew what I had and what the statistics told me about my chances of survival, and I was completely utterly terrified.

    Biweekly treatments of Acupuncture helped alleviated so many of the side effects of the Adriamycin/Cytoxan/Taxol and Carboplatinum, like nausea, sweet metal taste in my mouth, constipation, stomach pain, mouth sores, bone/joint pain, insomnia, memory loss, hot flashes, light-headedness, shortness of breath, rapid heart rate, trouble concentrating, lethargy, neutropenia and anemia. The fear and anxiety that come with a cancer diagnosis is overwhelming. Again Acupuncture helped alleviate my stress, fear and anxiety. I also was given IM injections of Neulasta and Neupogen post chemo to try and keep my white blood counts high enough to receive more chemo. These shots caused extremely intense bone pain, and worked at first but then not as well as time went on. I had to skip 2 doses of chemo due to low WBC’s. Julie performed WBC treatments to help to raise my counts, and the oncologists at Dana Farber were amazed when my WBC’s rebounded so quickly. There is nothing the oncologist can give you to keep up your red blood counts, and I required 4 blood transfusions, but I would have needed much more blood without Julie’s RBC treatments. Julie also helped me with my diet, giving me great suggestions about how to eat the best way to slow cancer growth. There were days when I couldn’t walk the 2 feet to my bathroom without assistance, and when laying my head on the pillow was too painful. On these days Julie fit me into her schedule for emergency appointments, and basically brought me back to life. I cannot stress just how sick I was. Many of my practitioners told me they had never see a person react so severely to chemotherapy, and I am so thankful that I had Julie to help with all the side effects.

    During the 9 months of chemo, surgery and radiation, which included an epic winter, my sessions with Julie kept me healthy. When my husband and I went on a plane in the middle of treatment, Julie’s treatments helped me to not get sick. When my husband came down with a stomach virus and then a cold, Julie’s treatment were why I did not get sick too. It made no sense that I wouldn’t get sick because my WBC’s were so low, I had absolutely no immunity. But, I never once got sick during treatment. Not once. I attribute that Julie and the Acupuncture treatments.

    Julie also performed specific BC Acupuncture treatments on me. All cancer patients hope for Pathological Complete Response (pCR) at the time of surgery. This significantly increases your chances of survival. My oncologist told me this would never happen for me as “there was too much cancer to start with.” Well I can’t say exactly why, but at the time of surgery in February 2015, I was declared NED (no evidence of disease) and had achieved pCR. I finished by 6 weeks of daily radiation in May 2015. I was told I had one of the worst BC diagnoses a person can have without being told they are stage IV, but had had the best response to treatment any cancer patient could ever hope for.

    I highly recommend Julie Permut and am a testament to how well Acupuncture works.

    Thank you Julie, you are an amazing healer and I’m so grateful to have found you <3

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