Reservations & Inquiries

Please fill out the required fields in the form below and click the “Submit” button.

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Required

Full Name Required
(in Roman letters)
Email Address　Required
Example: johnｘｘｘ@example.com
Phone Number 　Required
（Daytime Contact Number with country code)
Example: +1 234 567 890
Example: +1 234 567 890
Preferred Appointment Date and Time　Required
(Please provide 1st and 2nd choice)

1st choice

Example: April 1, 2025 – 10:00 AM

2nd choice

Example: April 1, 2025 – 12:00 AM
Treatment Menu　Required
(Prices include tax / Payment by cash only)
Non-medical, for relaxation purposes　（Prices include tax / Payment by cash only）
Country of Origin　Required
Example: Australia
　　For language support
Optional Fields

How did you hear about us?
Optional
Current Physical Condition / Symptoms　
Optional
Purpose or Goal of Treatment
Optional
Reason for Choosing Our Chiropractic
Optional
Any Precautions, Concerns, or Questions
Optional
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