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Name *
Phone *
Date of Birth *
Date of Birth
Preferred Date
Preferred Date
Best Time
Best Time
For patients using their health insurance, please provide all of the information below. Please include insurance company, insurance ID, group ID, and provider contact number (listed on the back of the card).

FINANCIAL POLICY - All payments are due at the time of the treatment unless arrangements have been made prior to your appointment. If you do not have health insurance that covers acupuncture services, please refer to our fee schedule. If you plan to use your health insurance, it is your responsibility to provide us with accurate information requested that would allow our office to verify your eligibility and benefits.

CANCELLATION POLICY - If you need to cancel an appointment, please give us a 24-hour notice in advance. Late cancellations will incur a charge of 50% of your scheduled treatment fees; no-shows will incur 100% of your scheduled fees. You, the patient, are fully responsible for this whether or not you are using health insurance or a third-party payer. The fee will be equal to our cash rates. Failure to pay this fee will prevent you from booking future appointments.

LATE POLICY - If you expect to run late to your appointment, please give us a courtesy notice. We will wait up to 10 minutes from the start time of the your appointment. If you arrive past 10 minutes, we may have to reschedule that appointment depending on how busy we are on that particular day. If you do not give us a notice and do not show up, the appointment will be marked as no-show in your record.