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Patient Form

Please fill in the following form to assist us with a complete assessment of your current condition and what you need assistance with. Details with your condition will assist in creating a targeted approach for your well-being. We will contact you as soon as possible with results and to identify the acupuncture cost for your treatment, as well as other information you need.

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Other Information

Emergency Information

Please indicate who to notify in case of emergency.


Please check if you have had (in the past three months):


If you would like other information about our treatments, such as acupuncture cost, types of treatments and what to expect, then please contact us. We are available to answer your questions at any time and are happy to assist you to reach a better state of health.