Health History
You careful answers to these question are very important to a proper diagnosis is Chinese Medicine, your attention to these questions is greatly appreciated. The Form is powered by G Suite and is HIPAA compliant.
Email address *
First Name *
Last Name *
Middle Initial
Birth Date *
MM
/
DD
/
YYYY
Home Address: street ,town, and zip code *
If you are a minor, please write your guardians name and phone number here:
Cell phone number *
Health Insurance Company (I only direct bill BCBS) *
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