New Patient Forms

For New

Adult Patients

Please fill out this detailed form as best as you can in order for us to tailor our services to best match your needs for a better result.

After finishing, please email the form to acubay88@gmail.com.

For New Children

(Pediatric Acupuncture)

For Pediatric Acupuncture, we also want parents to fill out this detailed form in order for us to better cater our services to match your childrens' needs in order to create a better result.

After finishing, please email the form to acubay88@gmail.com.

*** Only choose for Pediatric Acupuncture

Call us: (408) 828-3409

Email us: acubay88@gmail.com

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