Prospective Patient Inquiry Form

If you are interested in receiving care at our clinic, please complete our prospective patient inquiry form so we can assess your health needs and determine if our clinic is the best fit for your case. I will try to make a recommendation for alternate treatment or refer you to someone else if I think that is more appropriate for you. You will receive a response within 2 to 24 hours (48 if on a weekend). Please be sure to check your spam folder if you do not receive a reply within that time frame.

Please complete and sign our Consent Form and our Health Treatment Guide found at the bottom of this page as well. Thank you!

Our current clinic hours are Mondays, Wednesdays, and Thursdays, 9:30 am (first appointment) to 4:30 or 5:00 pm (last appointment). Do our hours work with your availability?

Yes

Yes, but with difficulty

Yes, but I need a specific time

I am planning to pay:

Out of pocket (no insurance)

I will submit to my insurance company once I receive my receipt

I understand that the clinic does NOT provide direct billing to insurance companies, SGI or WCB.

Most health issues require a minimum of 6-8 sessions, once per week for successful treatment. What is your expectation for treatment frequency?

to complete the recommended treatment, likely coming weekly for 2 months

don’t need regular care/only want to come when I feel the need

as long as it takes to heal my health issue

just want to try it, not ready to commit

monthly maintenance care

finances will determine my treatment frequency

How soon do you need an initial appointment (our clinic is often booked 1-3 weeks out)?

Ideally in the next 2 weeks

This week/immediately

I can wait 3-4 weeks

No rush/sometime in the next 1-2 months

Other

Consent Form - Open & Accept (Review Required)

You need to review and accept this before submitting

Acupuncture Health Treatment Guide (Review Required)

You need to review and accept this before submitting