Birds Nest Acupuncture
Please complete this questionnaire to request an appointment. This form is confidential and HIPPA compliant.

We will contact you back within 48-72 business hours (Monday through Friday). Thank you for your inquiry!

Email address *
Name *
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Phone number *
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What is the best way to contact you? *
What is the reason for your visit? *
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Is there an area in your life you would like to create a change? If so, please tell me about it. *
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This work relies on the therapeutic / healing relationship and takes time. Are you committed to investing in yourself? *
What is your availability for appointment times? Please indicate days of the week and time frames. *
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How did you hear about Birds Nest Acupuncture? *
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Please list any questions you have below:
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