Consultation

Name*

First and Last, please.

First Last

Consultation Preference*

Please select your preference for the consultation.

Video Skype
Audio Skype
Phone Call

Best Email*

Please use the same email as you gave when booking your consultation.

Phone Number*

Skype ID

Where do you live?*

City State / Province / Region

Were you referred by one of our happy patients?

If so, please type their full name.

First Last

What condition(s) are you currently suffering from?*

Check all that apply.

Which of the above conditions is your primary concern?*

How is this interfering with your life?*

Hint: What are you no longer able to do? What responsibilities or relationships are suffering because of this problem?

When did this problem first start?*

How many months or years ago?

What have you tried so far in an attempt to get relief? How has it helped or not helped?*

What do you feel is your biggest obstacle to fixing this problem?*

Right now I...*

Have the financial resources to invest in my healing and recovery.
Have access to the financial resources to invest in my healing and recovery.
I don't have any financial resources at all & I'm unable to invest in my healing and recovery.

If someone advised me to fly somewhere far from home and spend 2 weeks there in order to get better, I would...*

Know it's what anyone serious about their own recovery would do.
Would be a little intimidated, yet with a proven program of care I would do it because I am serious about getting better.
Avoid it at all costs because I want to do things as cheaply as possible.

Confirmation*

The doctor will call you at the time you chose. Please commit to your consultation appointment by typing this sentence in the box below: "Yes, I promise I will answer the phone for my consultation appointment when the doctor calls."

Consultation

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