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Thank you for considering care at the Rapha Clinic, and integrative Healthcare Centers, providing Acupuncture, Laser Light Therapy, Physiotherapy, Spine care and massage Therapy.

Please complete the following questionnaire to effectively and efficiently offer and

schedule your First appointment with us!

2. wht is the inensity of yur curren conition (0-10)?
3. Is the condition worse in the morning or evening?
9. Do you have a health insurance plan?
Or Upload Front of Ins. card
Uplad Back of Ins. card
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)

Thanks for submitting!

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