Your Name
Your Phone Number
Your Email
Where are you geographically located?
What is the health concern that brings you to Pine Street? (Exact diagnosis, staging, etc.)
Where are you going for your conventional treatment? (Name of institutions and doctors involved or being considered)
What conventional treatments are you currently doing or considering?
Who are you currently working with for your integrative and complementary treatment? (Names of all acupuncturists, naturopaths, functional medicine doctors, etc.) And how often are you seeing each of these practitioners per week or month?
What integrative or complementary treatments are you currently doing?
Why are you interested in an appointment at Pine Street?
Have you reviewed the Clinical Services page on our website, which outlines details such as fees and medical records?
   Yes      No

Is there a time of day or day of the week that's particularly convenient or particularly inconvenient for an appointment?
Any other notes?