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Your Full Name

Your Email

Your Phone Number

Your Full Address

Your Date of Birth

Who referred you to our practice? How did you learn about our practice?

Please list your top 3 health concerns:

What was going on when these symptoms started?

When was the last time you felt really well?

What do you think needs to change in order for you to feel better?

Are you willing to make dietary modifications, lifestyle changes, perform lab tests, take supplements, and be coachable?