Appointments

First name *

Last name *

Have you been to our clinic before *

No

Yes

Phone *

Is this a cell number *

Yes

No

Email *

Select a service
*

Appointment date 1st choice * +

Time 1st choice *

Appointment date 2nd choice * 🛈 +

Time 2nd choice * 🛈

Additional requests or comments

How did you find our clinic
*

-------------------

Privacy Notice and Consent for Electronic Submission:
*

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.

-------------------

Please be advised that your request is contingent on our availability and is pending. We'll notify you as soon as possible to confirm your appointment status. Thank you for your patience.