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Acupuncture Intake Form

If this is your first time booking in with us or haven't been to the clinic in over a year, please fill out the information below

Have you tried acupuncture before? Required
Select an option for your Gender
Do any of the following help you with pain? Required
Select from the following to describe your bowel movements Required
Do any of the following make your pain worse Required
How are you sleeping at night? Required
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