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Thank you for requesting an appointment with April Bui Holistic Acupuncture. Please note, this is only a request and is contingent on our schedule's availability. You will be notified as soon as possible regarding the availability status of your appointment. Thank you for your patience.
This appointment is for
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Myself
Another person
First name
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Last name
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Patient status
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New
Return
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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Contact person for this appointment
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First
Last
Name
First
Last
Email (please double check for accuracy)
*
Phone
*
Is this a cell number
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Yes
No
Who is this appointment for
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First
Last
Name
First
Last
Patient status
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New
Return
What is the primary health issue which you're seeking treatment for
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Select a service
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Free Consultation (does not apply to flower essence)
Acupuncture
Cupping
Flower Essence Therapy
Energy healing
Chakra Clearing & Balancing
Date 1st choice
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+
Time 1st choice
*
Date 2nd choice
*
🛈
+
Time 2nd choice
*
🛈
Do you currently have COVID-19 or within the past 30 days?
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No
Yes
When did your COVID-19 symptoms begin?
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When did your symptoms end?
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Have you been tested for COVID-19?
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No
Yes, result and date
Yes, result and date
How did you know about our clinic?
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Referred by my doctor
Referred by another person
Natural Awakening ad
Facebook
Internet search engine
I am an existing/return patient
Other
Additional request(s) or comment
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