Schedule Appointment – Westside Family Acupuncture

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Westside Family Acupuncture

New Hope in an Old Medicine

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Name *

First

Last

Please Provide Your Phone Number

Email *

Choose Preferred Times - Can Choose Multiple Times

Anytime works
Morning times from --- 9 am to 11:15 am
Afternoon times from - 11:45 am to 3:45 pm
Evening times from ---- 4:30 pm to 6:45 pm

Choose Preferred Days - Can Choose Multiple Times

Any day
As soon as possible
Mondays ----- ( Hours 9 am to 6:45 pm )
Tuesdays ----- ( Hours 9 am to 4:30 pm )
Wednesdays --( Hours 9 am to 4:30 pm )
Thursdays -----( Hours 9 am to 6:45 pm )
Fridays --------( Hours 9 am to 4:30 pm )
Saturdays only for Massage / True Testing

Please Choose Type of Appointment

Option to Choose a Second Type of Appointment

Do you wish to use insurance? Can Choose Multiple Choices

I am not sure
I would like to have my insurance benefits checked for me
I want to use my insurance
I want to self pay and not use insurance

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

Are you the Primary Insurance Holder

Yes
No

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 505-715-0099

5115 Coors Blvd. NW Suite E - Albuquerque NM 87120

New Patient Forms - Click and Print

New Patient Acupuncture Forms (Click Here) 01/2023
New Patient True Health Center Forms 2022

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