Kanata Acupuncture Chinese Acupuncture & Tuina Massage
J.P. Brunelle, Acupuncturist
Map to Office
Complete the following form and we will contact you to confirm your appointment.
Are you a new client? Yes No
If no, when was your last consultation?
Area of Concern
Interested in: Consultation Acupuncture Treatment Meet & Greet Only
Preferred Day: Monday Tuesday Wednesday Thursday
Preferred Time: 8:00 a.m. to 9:00 a.m. 9:00 a.m. to 10:00 a.m. 10:00 a.m. to 11:00 a.m. 11:00 a.m. to 11:30 a.m. 1:00 p.m. to 2:00 p.m. 2:00 p.m. to 3:00 p.m. 3:00 p.m. to 4:00 p.m. 4:00 p.m. to 5:00 p.m. 5:00 p.m. to 5:30 p.m.
First & Last Name:
Work Phone:
Home Phone:
Cell Phone:
Email Address:
We will contact you between 7:00 a.m. and 5:00 p.m.
Preferred method of contact: Home Phone Work Phone Cell Phone Email
Special Comments:
