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Dharma Reiki & Acupuncture
Appointment Request
Thank you for requesting an appointment with Dharma Reiki & Acupuncture. Please be advised that your request is contingent on our schedule's availability and is pending. We will notify you as soon as possible to confirm your appointment status. Thank you for your patience.
First name
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Last name
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Patient status
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New
Return or existing
Phone
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Is this a cell number
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Yes
No
Email (please double check for accuracy)
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Appointment Details
This appointment is for
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Fertility-related issues
Other conditions
If this is your first time seeking fertility-related treatment at our clinic, a preliminary consultation is required before any treatment modality may be given. Your consultation is free of charge.
Please click on Free Consultation button and select date/time for your appointment.
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Free consultation for fertility-related treatment
Date 1st choice
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+
Time 1st choice
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Date 2nd choice
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🛈
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Time 2nd choice
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🛈
Please select a service. All services include an initial consultation, assessment, and a treatment plan.
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Free consultation (choose this if you want only a consultation and no treatment)
Free consultation for Reiki distance healing
Acupuncture
Cupping
Reiki
Herbal therapy
I don't know, would like to have recommendation
Preferred method of consultation
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By phone
In-person
Date 1st choice
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+
Time 1st choice
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Date 2nd choice
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🛈
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Time 2nd choice
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🛈
What is the primary issue for which you're seeking treatment
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How did you find our clinic
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Internet search engine
Natural Awakening publication
Referred by a patient of Dharma Reiki & Acupuncture clinic
Referred by my doctor
Referred by another person or source
Facebook or other social media
Yelp
Healthprofs
Other
How did you find our clinic
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Internet search engine
Natural Awakening publication
Referred by a patient of Dharma Reiki & Acupuncture clinic
Referred by my doctor
Referred by another person or source
Facebook or other social media
Yelp
Healthprofs
Other
Additional request(s) or comment
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Privacy Notice and Consent for Electronic Submission of Form:
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By checking this box, I consent to the transmission of this form and all my information in this form electronically. I understand that Dharma Reiki & Acupuncture does not share, sell, rent, or trade any of my information in this form. I understand that this online form is serviced by Formsite and my data may be accessible by Formsite and their affiliates for the purpose of maintaining and regulating their services in accordance with their privacy policy. I understand that Dharma Reiki & Acupuncture has no control and no authority over the privacy policy and the usage of data collection of its online-service provider Formsite and any affiliates of Formsite. I understand that I have the options of requesting an appointment by phone, email, or in person.
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