Appointment Request Form

Full Name*

First NameLast Name

Gender at birth

Date of Birth:*

Phone*

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What days work best for you?*

TuesdayWednesdayThursdayFriday

What time works best for you?*

MorningAfternoonEvening

Any specific date/time? An appointment request does not guarantee a booking.

MonthDayYearHourMinutesAM/PM Option

What services are you interested in?*

Example: Acupuncture, massage, manual therapy, cupping, Chinese medicine, Thai yoga massage etc.

What condition you'd like to be seen for? (Bck pain, anxiety, migraines, digestive issues, etc).

Is your injury or illness due to any of the following:*

Do you have health insurance? If so, please submit an insurance verification request once this form is completed. You may access it on our home page.*

YesNo

HOLD DEPOSIT - Due to the high demand and limited availability of new patient appointments, a $50 deposit is required to hold all new patient appointments. We do not require a new patient deposit for veterans booked through the VA.

Your deposit will be applied to the cost of your visit or held on account to cover your copays, coinsurance, or purchases. If you have a $0 copay on your insurance, this deposit will be refunded back to your credit card once your claim is paid by your insurance.

We realize that sometimes life puts obstacles in our way and there are times a person simply can't make it and isn't able to provide two business days' advance notice to cancel or reschedule. That's okay! We understand, and there are no hard feelings. That's what the deposit is for. Though it won't cover the full cost of your visit, it will help us ensure your provider doesn't experience any lost wages.

Patients who have not been seen in one (1) or more years are considered new patients. If you make an appointment and/or pay a deposit on behalf of another person, you are responsible for any late cancellation/no-show fees they may incur.

DEPOSIT PAYMENT: You may pay it over the phone, or by visiting: https://eastlakeacu.com/shop-our-store/ols/products/deposit-to-hold-appointment. We are happy to text you a direct link if you like.