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

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

Who is this appointment for *

	First	Last
Name	First	Last

Patient status *

New

Return

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

Select a service *

Date 1st choice * +

Time 1st choice *

Date 2nd choice * 🛈 +

Time 2nd choice * 🛈

Do you currently have COVID-19 or within the past 30 days? *

Yes

When did your COVID-19 symptoms begin? *

When did your symptoms end? *

Have you been tested for COVID-19? *

Yes, result and date Yes, result and date

Additional request(s) or comment