Thank you for choosing April Bui Holistic Acupuncture for your health care. Please note, this is only a request and is contingent on current availabilities on our schedule. We will notify you as soon as possible regarding the availability status of your request.

This appointment is for *

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First name *

Last name *

Patient status *

New

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Email *

Phone *

Is this a cell number *

Yes

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Contact person for this appointment *

	First	Last
Name	First	Last

Email *

Phone *

Is this a cell number *

Yes

No

Who is this appointment for *

	First	Last
Name	First	Last

Patient status *

New

Return

Briefly describe the health issue which you're seeking treatment for *

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Date - 2nd choice * 🛈 +

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COVID 19 - are you currently experiencing or had experienced in the past any COVID-19 symptoms? * 🛈

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.

Have you been tested for COVID-19? *

Tested negative.	Have not been tested.
Tested positive.

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