Step 1 of 6 16% Patient InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Male Female Email(Required) PhoneAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Healthcare ConcernsTell us your top 3-4 concerns you would like addressed.(Required)Please be as detailed as possibleHealthcare ConcernDetails (Include symptoms and timeframes) Add RemoveWhat providers have you seen for your concerns?(Required)Dr. NameSpecialtyLast Date Seen Add Remove Healthcare Concerns (Continued)What other treatments / therapies have you tried previously and where they helpful?(Required)Treatment/TherapyHelpfulnessDetail Add RemoveDo you have any specific therapies or testing that you are interested in, or looking for?(Required) Current MedicationsList all prescriptions, over the counter medications, and supplements you are taking.(Required)Please bring your prescriptions and supplements, in their original bottles, to your first appointment.Rx / OTC Medication / SupplementDosageFrequency Add Remove Healthcare GoalsOn a scale of 1-10, to accomplish your goals, how willing are you to incorporate the following:Nutrition and Lifestyle Changes(Required)Please enter a number from 1 to 10.Supplements into Your Daily Routine(Required)Please enter a number from 1 to 10.Infusion Therapy into Your Treatment(Required)Please enter a number from 1 to 10. Other ConsiderationsDo you have any previous testing you would like to be considered?(Required)Is there anything else we should know that would help us determine what kind of appointment you will need?(Required)Are there any personal needs or limitations (such as geographical proximity, financial concerns, physical or sensory challenges, or time constraints) we should be aware of in order to better support you during your care?(Required)PhoneThis field is for validation purposes and should be left unchanged. Δ