Public Health Survey

How Can Acupuncture Help Me?

Your Name:

Your Email Address:

Your Phone Number:

Do you have any of the following risk factors?

Check any of the following that apply:

Any Additional Questions or Comments on the Above Risk Factors or Conditions?

After this evaluation, I have agreed to be contacted by Dr. Ruth Lacayo L.,Ap and possibly set up an appointment for treatment.

Electronic Signature (Type Your Full Name):

Today’s Date:


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