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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.
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
*
Yes
No
Who is this appointment for
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First
Last
Name
First
Last
Patient status
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New
Return
Appointment Details
What is the primary health issue which you're seeking treatment for
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Please select a service. All services include initial consultation, assessment, and a treatment plan.
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Free Consultation (choose this if you want only a consultation without any service)
Acupuncture
Cupping
Cupping with acupuncture
Reiki
Reiki with acupuncture
Herbal therapy
I don't know, would like to have recommendation.
Date 1st choice
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+
Time 1st choice
*
Date 2nd choice
*
🛈
+
Time 2nd choice
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🛈
Have you experienced any COVID symptoms within the past 30 days or any respiratory, sinus conditions in the past 7 days?
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No
Yes
When did COVID and/or respiratory, sinus symptoms begin?
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When did COVID and/or respiratory, sinus symptoms end?
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Have you been tested for COVID?
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No
Yes
Date of your most recent COVID test
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Test result
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Negative
Positive
How did you know about our clinic?
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Referred by a patient of Dharma Reiki & Acupuncture
Referred by my doctor
Referred by another person or source
Natural Awakening magazine
Social media
Yelp
Healthprofs.com
Internet search engine
Other
How did you know about our clinic?
*
Referred by a patient of Dharma Reiki & Acupuncture
Referred by my doctor
Referred by another person or source
Natural Awakening magazine
Social media
Yelp
Healthprofs.com
Internet search engine
Other
Additional request(s) or comment
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