Name *

First Name

Last Name

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Select time you want to come in. *

10:30 am - 12:00 pm

12:00 pm - 2:00 pm

3:00 pm - 5:00 pm

5:00 pm - 7:00 pm

Date of Birth

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DD

YYYY

We are an out of network provider. Your coverage depends on your out-of-network benefits. *

I understand.

Name *

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Select time you want to come in. *

10:30 am - 12:00 pm

12:00 pm - 2:00 pm

3:00 pm - 5:00 pm

5:00 pm - 7:00 pm

Are you aware that the Groupon voucher is one time use only per patient? *

Yes (I am a new patient and never been to Choice Acupuncture before.)

No (If you purchased another voucher, you cannot use it. Kindly contact Groupon for refund.)

Are you a new patient? *

Yes

No

Name *

First Name

Last Name

Phone *

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Select time you want to come in. *

10:30 am - 12:00 pm

12:00 pm - 2:00 pm

3:00 pm - 5:00 pm

5:00 pm - 7:00 pm