Prospective Patient Inquiry Form

Full name, including preferred name if different:

Email Address (prefered contact method)

Phone Number (optional)

How did you hear about our clinic?

What are your health concerns that you would like to address?

Our current clinic hours are Mondays, Tuesdays, and Thursdays, 9:30 am (first appointment) to 2 or 2:30 pm (last appointment). Do our hours work with your availability? Our current clinic hours are Mondays, Tuesdays, and Thursdays, 9:30 am (first appointment) to 2 or 2:30 pm (last appointment). Do our hours work with your availability? Yes No Yes, but difficult Yes, but I need a specific time

My specific time requested is

I am planning to pay: I am planning to pay: Out of Pocket Use Insurance

If you are planning to use your insurance, have you verified that our clinic can take your policy? If you are planning to use your insurance, have you verified that our clinic can take your policy? Yes No

Most health issues require a minimum of 6-8 sessions, once per week for successful treatment. What is your expectation for treatment frequency? Most health issues require a minimum of 6-8 sessions, once per week for successful treatment. What is your expectation for treatment frequency? to complete the recommended treatment, likely coming weekly for 2 months don’t need regular care/only want to come when I feel the need as long as it takes to heal my health issue just want to try it, not ready to commit monthly maintenance care finances will determine my treatment frequency

Frequency due to finances

What is your level of willingness to resolve the health issues you described above (5 being very committed)? What is your level of willingness to resolve the health issues you described above (5 being very committed)? 1 2 3 4 5

How soon do you need an initial appointment (our clinic is often booked 1-3 weeks out)? How soon do you need an initial appointment (our clinic is often booked 1-3 weeks out)? Ideally in the next 2 weeks This week/immediately I can wait 3-4 weeks No rush/sometime in the next 1-2 months Other

Other option for first appointment