Your name

Your email

Your phone

What insurance do you have?

How did you hear about us and/or referred you to us?

At your initial visit, what are your primary and secondary health concerns that you would like to discuss? (Please limit your response to 2 major health concerns for your initial visit)

How long have you had these conditions?

Who are you currently seeing for this condition and how are they treating it?

What medications are you currently taking? (Please include dosage and frequency)

Have you had any testing (blood work and/or radiology exams) in the past year? Once your appointment has been scheduled, please send us a copy of any reports.

What is your expectation from us?

We are looking for patients who are motivated and focused and committed to improve their healthcare. Are you willing to collaborate with the doctor including possible follow up appointments if needed, nutraceutical supplementation as written and prescribed by the provider, lab/blood work, dietary changes and/or lifestyle changes? If not, please explain your concerns.

Any additional information you would like to share(optional)