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. 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

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

Select a service *

Date 1st choice * +

Time 1st choice *

Date 2nd choice * 🛈 +

Time 2nd choice * 🛈

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.

Describe the COVID-19 symptoms you're having and how long have you had them? *

When did you experience COVID-19 symptoms and for how long? *

Do you still have any lingering COVID-19 symptoms that we should be aware of? If yes, please describe. *

Have you been tested for COVID-19? Select all that aplies. *

Tested negative.

Tested positive.

Have not been tested.

Date of test which you tested negative. *

Date of test which you tested positive *

Additional request(s) or comment