Last Step!

Home Visit Request Form

Please fill the form below to submit a home visit request. We kindly ask that you submit your request at least 48 hours in advance.

Street Address *

Postal code *

First Name *

Last Name *

Email *

Phone *

Service(s) Needed: *

Acupuncture - Initial Consultation & Treatment (85min)

Acupuncture - Follow-up Consultation & Treatment (60min)

Acupuncture - Focused Follow-up Consultation & Treatment (45min)

Facial Acupuncture (90min)

Date: *

Time Preference: (you can choose multiple) *

Morning (9am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-8:30pm)

Additional Details: (optional)

Please add any context you believe we should be aware of.

I have read and agree with the Terms of Service.