First Name

Last Name

Phone *

Email *

Date of birth *

What is the main health concern or condition you’re seeking help for? *

How long have you been experiencing this condition? *

Have you been formally diagnosed? *

Yes

What treatments or approaches have you tried so far? *

Are you currently under a doctor’s care for this condition? *

Yes

On a scale of 1–10, how committed are you to resolving this condition? *

Do you have the time and flexibility in your schedule to commit to a treatment plan if we determine we can help *

Yes

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 have access to resources to invest in my health.

I don’t have liquid funds but am willing to explore financing options to get the care I need.

I do not currently have the resources to invest in my health, and I am not willing to explore financing options at this time.

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