First Name
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Last Name
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Phone
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Email
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How old are you?
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What are you the top health concerns that you would like us to help you overcome?
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Why is this goal important to you, and what do you think is stopping you from accomplishing it?
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Who else have you worked with?
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Functional Medicine Practitioner
Medical Doctor/Osteopathic Doctor
Medical Specialist
Naturopathic Doctor
Traditional Chinese Medicine
Nutritionist/Dietician
Personal Trainer
Chiropractor
Personal Development Coach
Other
If Other:
In The Last 3 Months, Have You Had Any Of The Following Symptoms?
Anxiety
Depression
Chronic Pain
Fatigue
Bloating
Memory lapses
Quick weight gain or loss
Tremors
Racing heart and mind
None
If Other:
How Did You Find Us
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Referral
Online Search ( Google, Safari, Or Bing )
Facebook
Instagram
Other
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Cash Only Acknowledgement
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I understand that we only accept cash, check, and credit cards.
I understand that I will be given a bill if I want to attempt to get reimbursed by my insurance if I have it.