Schedule Appointment – Westside Family Acupuncture

New Hope in an Old Medicine

Name *

First

Last

Please Provide Your Phone Number

Email *

Choose Preferred Times - Can Choose Multiple Times

Choose Preferred Days - Can Choose Multiple Times

Please Choose Type of Appointment

Option to Choose a Second Type of Appointment

Do you wish to use insurance? Can Choose Multiple Choices

Name of Insurance Company (Please Provide the Following to Verify Insurance Benefits or Call)

Are you the Primary Insurance Holder

Please Provide Group Number (It is on your insurance card)

Please Provide Member ID Number

Please Provide Reason for Visit ( example - Low back pain)

Please Provide Date of Birth (use to verify benefits)

Ph. 505-897-6560 - Fax 505-715-5537