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 *

Myself

Another person

First name *

Last name *

Patient status *

New

Return

Phone *

Is this a cell number *

Yes

No

Email (please double check for accuracy) *

Contact person for this appointment *

	First	Last
Name	First	Last

Email (please double check for accuracy) *

Phone *

Is this a cell number *

Yes

No

Who is this appointment for *

	First	Last
Name	First	Last

Patient status *

New

Return

Appointment Details

What is the primary health issue which you're seeking treatment for *

Please select a service. All services include initial consultation, assessment, and a treatment plan.
*

Date 1st choice * +

Time 1st choice *

Date 2nd choice * 🛈 +

Time 2nd choice * 🛈

Have you experienced any COVID symptoms within the past 30 days or any respiratory, sinus conditions in the past 7 days? *

No

Yes

When did COVID and/or respiratory, sinus symptoms begin? *

When did COVID and/or respiratory, sinus symptoms end? *

Have you been tested for COVID? *

No

Yes

Date of your most recent COVID test *

Test result *

Negative

Positive

How did you know about our clinic? *

Additional request(s) or comment