Appointment Request Form

Full Name*

First NameLast Name

Phone *

Phone Number

E-mail*

What days work best for you?*

What time works best for you?*

MorningAfternoonEvening

Date

I would like a:

In-clinic appointment at Balanced Living ClinicVirtual appointment via zoom

I would like to see the following Practitioner:

Jennifer Lewin - Licensed Acupuncturist & Herbalist, Integrative Manual Therapist, Functional Medicine PractitionerToni Baker - BHSc (Naturopathy), Adv Dip Western Herbal Medicine, Adv Dip Nutrition, Dip Homeopathy, Dip Remedial Massage, Dip Reflexology, Emotion Code PractitionerDana Heather - Homeopath, Nutritionist, Functional Medicine PractitionerKaren Taylor - Reiki Master Teacher & Practitioner, Hypnotherapist, Yoga Teacher

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