Do you have an autoimmune condition or suspect you might? *

What's your first name? *

Which best describes your current situation? *

What's your best email? *

What's your last name? *

What's your phone number? *

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What health challenges are you facing? (Select all that apply) *

How long have you been struggling with these issues? *

Are you prepared to invest in your health? *

Who makes health decisions in your household? *

If accepted, How soon are you looking to get help? *

If we schedule a consultation, will you commit to showing up? *