What's the main symptom you're struggling with right now? *

*Neuropathy* (Nerve damage causing pain, numbness, tingling, or weakness—usually in hands and feet)

*Autoimmune Disorders* (symptoms might include: fatigue, joint pain or swelling, skin rashes, digestive issues, recurring fevers, muscle aches, brain fog or difficulty concentrating)

*Fibromyalgia* (Chronic condition causing widespread pain, fatigue, sleep issues, and cognitive difficulties)

*Hormone disorders* (Symptoms include: unexplained weight gain or loss; fatigue; mood swings, anxiety, or depression; irregular periods or fertility issues; hair thinning or excess hair growth; sleep disturbances; hot flashes or night sweats; and more)

Other

If other, please describe below.

How long have you been experiencing this? *

Less than 2 weeks

2 weeks to 3 months

3 months to 1 year

Over 1 year

How is this affecting your daily life? *

How urgent is finding a solution for you? *

I need help immediately

Within the next week

Within the next month

Just exploring options

First Name *

Last Name *

Phone *

Email *

On a scale of 1-10, how committed are you to making a change right now? *

Not Very CommittedExtremely Committed

Are you willing to invest time, energy, and financial resources into fixing this problem? *

Yes

If you qualify for care, are you able to get to our office located in Summit, New Jersey 1-2 times per week? *

Yes

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