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 *

Myself

Another person

First name *

Last name *

Patient status *

New

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Phone *

Is this a cell number *

Yes

No

Email *

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 *

Please select a service *

1st choice for date * +

1st choice for time *

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? * 🛈

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 comment or request(s)