New Patient Intake Form - please submit this form prior to booking if you are hoping to use your insurance benefit so we may verify your coverage. Mahalo!

Name:*

Phone Number:

Mailing Address (optional but required for insurance):

Email:

Date of birth (must include for insurance eligibility):

Insurance Information - Please specify the name of Insurance Company. We accept ASHN, KAISER HAWAII, HMSA, UHA, HMAA, HUMANA & UNITED HEALTH ONLY! WE DO NOT ACCEPT ANY OUT OF STATE POLICIES! If you do not have one of the above mentioned policies, please skip this section!

Insurance ID number (must include for insurance eligibility):

Please list your goals for acupuncture treatment:

Please list all medications and supplements:

Please explain any relative history related to your condition:

This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Your message was sent successfully.

If you are a visitor or traveler that has returned to the island within the past 14 days, please text a copy of your negative COVID test result to (808)250-7663, prior to your appointment. Mahalo!

"Health is the greatest possession. Contentment is the greatest treasure. Confidence is the greatest friend. Non-being is the greatest joy! " -Laozi

New Patient Intake Form - please submit this form prior to booking if you are hoping to use your insurance benefit so we may verify your coverage. Mahalo!

If you are a visitor or traveler that has returned to the island within the past 14 days, please text a copy of your negative COVID test result to (808)250-7663, prior to your appointment. Mahalo!​

If you are a visitor or traveler that has returned to the island within the past 14 days, please text a copy of your negative COVID test result to (808)250-7663, prior to your appointment. Mahalo!