Acupuncture Booking Form (Eng/Chi)

Acupuncture Booking

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 ? *

有 Yes, I have been没有，现在填写资料 No, fill in your details below我想申请新的ACC号(因为有新的受伤）I would like to apply new ACC with a new injury
Referred by 被谁转介:

Dr Jessie Liu 刘医生Dr Ruoh Sim 沈医生Acupuncturist Ren Jie 人杰中医师推拿师Other
姓名 Full Legal Name ：*

Title称呼 First Name 名 Last Name 姓
手机号 Mobile ：*
phone number
出生日期 Date of Birth:

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

1st Acupuncture（第一次针灸推拿）2nd Acupuncture (第二次针灸推拿）3rd or more Acupuncture (第三次或以上针灸推拿）Other
- 性别 Gender ：*
  
  男 Male女 FemaleOther
- 种族资料 Ethnicity Details*
  
  NZ EuropeanChinese 中国人/华人MaoriSamoanCook Island MaoriTonganNiueanIndianOther
- 电子邮箱 Email：
  example@example.com
- 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
- 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)
  
  Payment link to be texted to patient 付款链接短信发给您Payment link to be emailed to patient付款链接邮件发给您Payment by cash/ eftpos at Caring Clinic Doctors在怀爱诊所前台付款Payment by Cash on site (to Acupuncturist)直接现场现金付款Other
- Should be Empty: