Name *

First Name

Last Name

Patient Status *

New Patient

Returning Patient

Phone *

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Date of birth *

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DD

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Treatment seeking (select all that apply)

Standard TCM: Acupuncture + Herbal Medicine

Premium Integrative Health: Acupuncture and Herbal Medicine + Functional Medicine, Lab Testing, and Evaluation

Bodywork and Massage

Yoga Therapy

Reiki

Fertility Support (Male and Female factor labs are required within the last 6 months; if unable please let us know so we can assist)

Appointment time preference

Morning

Afternoon

Evening