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.
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)
I do not have insurance
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This form was created inside of Jeff Shih-chung Matrician, Licensed Acupuncturist.