First Name
Last Name
Phone
*
Email
*
What is the main health concern or condition you’re seeking help for?
*
Have you been formally diagnosed?
*
Yes
No
What treatments or approaches have you tried so far?
*
Are you currently under a doctor’s care for this condition?
*
Yes
No
On a scale of 1–10, how committed are you to resolving this condition?
*
1
2
3
4
5
6
7
8
9
10
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Do you have the time and flexibility in your schedule to commit to a treatment plan if we determine we can help
*
Yes
No
When are you looking to solve the above symptoms?
Now
Next week
Next Month
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This type of care requires a commitment to your health and the belief that investing in your well-being is worthwhile. If we find a solution for your health, which of the following best describes your situation?
I am able and ready to invest in my health.
I am able to finance this investment for my health.
I am unable to invest in my health, and I am not willing to explore financing options at this time.
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