Name *

First Name

Last Name

Phone *

(###)

###

####

Will you be using Health Insurance? *

If yes, please submit your insurance info below. Benefits must be verified before appointments can be scheduled.

YES (If yes, please include insurance information in next entry field)

NO

Appointment Availability *

Please check your general availability for appointments

Morning

Afternoon

Evening

Day Availability *

Please check all times that generally be a good fit for appointment scheduling regularly. We will use this information to match you with the Acupuncturist who works shifts that align with your scheduling needs.

Monday (5pm - 8pm)

Tuesday (9am - 12pm)

Tuesday (2pm - 6:30pm)

Wednesday (10am-2pm)

Wednesday (2pm - 7pm)

Thursday (10am - 2pm)

Thursday (2:00pm - 6:30pm)

Friday (8:30am - 12pm)

Friday (12pm - 2pm)

Saturday (10am - 1pm)

Saturday (1pm - 5pm)