Acupuncture Booking Form (Eng/Chi)

Acupuncture Booking针灸推拿预约

Address: 7 Puriri Avenue, Greenlane, Auckland Phone 09 5539888 Email: unityacupuncturenz@gmail.com
您来过本诊所吗？ Have you been to our clinic before ?
姓名 Full Legal Name ：

Title称呼 First Name 名 Last Name 姓
手机号 Mobile ：
phone number
电子邮箱 Email：
example@example.com
Date of Birth 出生日期:

DayMonthYear
Date
Today's Date

DayMonthYear
Date
Calculation
Please select applicable treatment 请选您的治疗阶段：

Other
- 性别 Gender ：
  
  Other
- 种族资料 Ethnicity Details
  
  Other
- 住址 Address :
  
  street address
  
  Street Address Line 2
  
  City 城市State / Province
  
  Postal / Zip CodeCountry 国家
- Please upload a copy of any photo ID (i.e. Passport/ Driver license/student ID with photo) - suggestion: scan and add, or take a photo and attach. (optional)
  
  Browse Files
  can upload more than one files (including jpeg/ pdf etc) Cancelof
- Take Photo of your ACC form if you have:
- Date of injury 受伤日期：
  
  DayMonthYear
  Date
- Occupation 职业：
- Area of injury 受伤部位：
- Describe your injury/ accident (how /where/ which body part): 请简单描述受伤经过和部位：
  please include body parts affected/ how it happen / location eg I slipped and hurt the lower back. 我在厨房里摔伤了腰部。
- Appointment 预约：
- If you have any other queries/ comments（若有其他情况，也可以在此告知）:
- Methods of payment (付费方式） : (prepay preferred 提倡预付)
  
  Other
- Date to send email for nxt booking
  
  DayMonthYear
  Date
- Should be Empty:

Acupuncture Booking针灸推拿预约