Full Name

State

Email *

Phone *

Preferred Method of Communication

Text

Phone Call

What are your top 3 health concerns?

Please rate the urgency of addressing your concerns:

5 = Extremely Urgent

1 = Not Urgent At All

What have you tried to resolve your health issues?

Other Doctors

Pharmaceutical Medications

Diets

Vitamins, Herbal or Nutritional Supplements

Physical Therapy

Talk Therapy

Other

Would you like to see if your insurance will cover our health & wellness services?

Yes

If yes, your date of birth and zip code are required to verify your insurance

Postal Code

Date of birth

If yes to insurance, please upload your insurance card here:

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

If not using insurance, you may skip to the next question

Some insurances cover some naturopathic medical services, some cover none, which best describes your current situation?

I have the financial resources to invest in fixing my health even if insurance doesn't cover it.

I can get access to the financial resources to invest in my health even if insurance doesn't cover it.

I am unable to invest outside of my insurance coverage at this time.

N/A

Why are you looking for help now?

I am unhappy with the results of previous treatments

I am unhappy with what my insurance currently covers

I am hopeful that natural medicine will work better and be safer

I have had previous positive experiences with natural medicine or functional medicine.

Other (please specify below)

How did you hear about us?

Friend/Family (please list below)

Referral from another professional (please list below)

Google Search

Social Media

Other (please specify below)

Who referred you?

Do you have any preference on which specialist you'd like to schedule with?

Please schedule the best time for a quick 15 minute consult!