This quick questionnaire will help us determine if you might be a good candidate for our treatments at Omega Health Clinics. Please answer the following questions to the best of your ability.

Agreement *

OK

📢 How did you hear about this?

Source *

Online Search

Social Media

Word of Mouth

Advertising

Referral (Friend/Family)

🤒 Do You Have A Chronic Illness That Requires Ongoing Treatment?

Chronic Illness *

Yes

No

💉 Has Your Healthcare Provider Recommended IV Infusions As Part Of Your Treatment Plan?

IV Infusion Recommendation *

Yes

No

✅ Which Of The Following Chronic Illnesses Do You Have? (Check all that apply)

Chronic Illness Types *

Rheumatoid Arthritis

Crohn's Disease

Multiple Sclerosis

Psoriasis

Ulcerative Colitis

Lupus

Asthma

Other

Chronic Illness Type Other

💳 Are You Currently Covered By Any Of The Following Insurances?

🏥 Where Are You Currently Receiving Your Infusion?

Infusion Location *

Hospital

Home

Infusion Center

🙋 Please Share Any Additional Comments or Questions You May Have.

Additional Information

Contact information

If you would like us to follow up with you, please provide your contact information.

First Name *

Last Name *

Email *

Phone *

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