Intake form

Name *

Email address *

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?

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?

What is your availability for appointments?

Please select at least one option.

Weekdays

Weekends

Mornings

Afternoons

Evenings

How did you hear about us?

Do you have any specific goals for your treatment?

Additional questions or comments

Resilient Body Acupuncture & Wellness