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Thank you for considering care at

the AcupunctureDrs @ Rapha Clinic,

an Integrative Healthcare Centers.

​

Please complete the following questionnaire to effectively and efficiently offer and

schedule your First appointment with us 

2. What is the intensity of your current symptoms (0-10)?
9. Do you have a health insurance plan?
Or Upload Front of Ins. card
Max File Size 15MB
Uplad Back of Ins. card
Max File Size 15MB
10. Where is your Preferred Location for your Acupuncture treatment? (check all that apply)
11. When is your preferred days and times for your Acupuncture treatment? (check all that apply)
Thank You for Submiting
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