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Intake form
Help us serve you better
Name
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Email address
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What is your primary reason for seeking acupuncture or wellness services?
Please select at least one option.
Pain management
Stress relief
Improved sleep
Enhanced immunity
Digestive issues
Emotional well-being
General wellness
Have you received acupuncture treatment before?
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Yes
No
What health conditions are you currently experiencing?
Please select at least one option.
Chronic pain
Anxiety
Depression
Allergies
Insomnia
Digestive problems
Migraines
Are you currently taking any medications?
Do you have any allergies or sensitivities?
What is your preferred method of communication?
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Phone
Email
Text
What is your availability for appointments?
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Weekdays
Weekends
Mornings
Afternoons
Evenings
How did you hear about us?
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Referral
Social media
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Do you have any specific goals for your treatment?
Additional questions or comments
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