Worksheet

Application for Discovery Consultation with Robin

1.

Ready to resolve your child's health issue?

Great! 

To get started, please take a quick moment to fill out our application. Then you'll be redirected to our online schedule to book your free 15-minute Discovery Consultation.

2.

First & Last Name

3.

Child's Name

4.

Child's Age

5.

City, State, Country where you live

6.

Briefly describe the health problem your child is struggling with

7.

List Your Top 3 Questions Regarding this Health Concern

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8.

To Solve this Health Concern, are you willing to make changes to your or your child's diet, lifestyle, and routines?

9.

On a scale of 1 - 10 (10 being the most), how committed are you to doing whatever it takes to solve this health problem?

10.

Is there anything else we should know before scheduling this Discovery Consultation?

11.

What is the best number to text you at?

12.

What time zone are you in?

13.

That's it!

Thanks for completing the application. Please be sure to click the button to submit your answers.

You will be redirected to our online booking service where you can book your Discovery Consultation. 

I look forward to chatting with you soon!

Robin Green Acupuncture, Inc. · 15585 Monterey St., Ste E · Morgan Hill, CA 95037 · United States
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