Name *

First Name

Last Name

Mailing Address

Address 1

Address 2

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DD

YYYY

Home Phone

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Date

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Acupuncture

Services Provided: I understand that acupuncture serves individuals with a wide range of complaints including both acute and chronic healthcare concerns. I understand that I may be treated with the insertion of needles and/or with the application of heat to the skin.

Yes

No

Herbal Consultation

Services Provided: I understand that medicinal herbs are considered to be a food supplement and are utilized to strengthen and support overall health and wellness. Herbs, along with nutritional suggestions can serve as an excellent adjunct to a medical doctor's treatment, but are not a replacement substitute for that treatment.

Yes

No