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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. We appreciate 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
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Contact person for this appointment
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First
Last
Name
First
Last
Email
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Phone
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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
Briefly describe the health issue which you're seeking treatment for
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Please select a service
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Free Consultation
Acupuncture
Cupping
Flower Essence Therapy
Chakra Clearing/Balancing
1st choice for date
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+
1st choice for time
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2nd choice for date (optional but recommended)
🛈
+
2nd choice for time
COVID 19 - are you currently experiencing or had experienced in the past any COVID-19 symptoms?
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🛈
No, I currently do not experience any COVID-19 symptoms.
I had COVID-19 symptoms in the past but is now cleared.
Yes, I am currently having active COVID-19 symptoms.
Describe the COVID-19 symptoms you're having and how long have you had them?
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When did you experience COVID-19 symptoms and for how long?
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Do you still have any lingering COVID-19 symptoms that we should be aware of? If yes, please describe.
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Have you been tested for COVID-19? Select all that aplies.
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Tested negative.
Tested positive.
Have not been tested.
Date of test which you tested negative.
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Date of test which you tested positive
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Additional comment or request(s)
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