New Patient Application

New Patient Application

Infinity Holistic Healthcare
Please fill out the application below so that we can learn about your health goals. We will contact you soon-either to schedule your complimentary chemistry call with Dr. DiNezza or to try to help you in some other way.

Please note- the purpose of the chemistry call is to make sure that our goals are well aligned before booking you for an appointment. Medical and/or nutrition advice will not be discussed on this call.
1. First and Last Name *
2. Date of Birth *

Month Day Year
Date
3. Email address *
example@example.com
4. Cell phone number *
5. Zip code (if in the USA) or Country *
IMPORTANT - PLEASE READ

My top priority is to help you feel better as soon as possible. And, as I'm sure you're aware (since you're filling this out), finding the right person/people to guide you is critically important.

I practice very differently than what you might expect. Oftentimes, people expect the following: We gather information (questionnaires, first appointment, lab testing), I tell you your diagnoses/what's wrong, I lay out your multi-month treatment plan, we follow that treatment plan, and then you feel better.

But, healing is rarely that linear and predictable, even for someone with my experience. Rather, I find that we need to be flexible and adapt your care plan as we learn more about your body, what it likes, and what it doesn't like. So, our work together usually looks like this:
1. We gather information (questionnaires, first appointment, lab testing)
2. We discuss what is likely going on (hypothesis #1) ("X is most likely based on the information we've collected, but it's possible that Y is involved, too")
3. I recommend things that will help you if hypothesis #1 is correct
4. We gather more information (via following-up and discussing how you did with treatment #1) (ex. "A made me feel a bit better, but I think B made me feel worse")
5. We tweak our hypothesis and I make new recommendations based on this information
6. Then, we repeat #4 and 5 every few weeks until you feel better (with occasional lab testing, if needed)
This is what I have found to be most effective. However, I have come to realize that this methodology can provoke anxiety in those who deeply crave concrete answers or are afraid of uncertainty.

You know your body and mind better than anyone else- please take a moment to pause and think if this type of doctor/patient relationship will work best for you.
6. What are your top three symptoms you are seeking help with? *
7. If you could wake up tomorrow WITHOUT these symptoms/challenges, how would your life be different? What things would you do that you cannot do now?
What are you looking for in your healthcare provider and their team? Check all that apply.

Listens to me Looks at the big picture (holistic) Does things naturally whenever possible Collaborates with me so that I can make informed healthcare choices Helps me order and understand test results or reach an appropriate diagnosis Ongoing support and accountability so that I never feel stuck or lost
Do you follow a specific dietary template? For example, Paleo/Ancestral, Weston A Price, Keto, Vegan, Vegetarian, or the Blood Type Diet? If yes, are you willing to change your diet and/or what you believe about nutrition?
Please answer the next set of questions on a scale of 0-10.

0 = Not at all open/willing

10 = Highly open/willing
How willing are you to make dietary changes that involve ADDING foods to your diet? (ex. meat, fat, carbs, fiber, high FODMAP foods) *
How willing are you to make dietary changes that involve STRICTLY SUBTRACTING foods from your diet? (ex. gluten or dairy) **Please note this is not typically something I am keen to recommend** *
How willing are you to make lifestyle changes? (ex. start meditation, modify your work schedule, modify your sleep schedule, address stressful relationships) *
How willing are you to take herbs and/or supplements? *
How did you learn about me?

Youtube Google or internet search IBS Freedom podcast Another podcast Facebook Instagram TikTok Referral from another provider Referral by another patient Health fair or expo Online summit Other:
The purpose of the chemistry call is to make sure our goals are well aligned and that we'll be a good fit to work together. Medical and/or nutrition advice will not be discussed on this call. *

Ok, I understand! No, I expect you to coach me on the fly
The best, longest lasting healing comes from steady momentum and accountability. If you wish to work with our office you will be asked to invest in a care program that is 6 months in duration for $7,985. This does not include lab testing or supplements. Are you willing and able to invest $7,000-10,000 in your future at this time? *

Yes, if our call goes well and my questions are answered I am willing and able to invest in my health No
Are you aware that your 6 month care plan must be paid in full at the time of your first full-length appointment? (payment is not due at the chemistry call) *

Yes, I understand that I must pay in full at my first full-length appointment No
Are you aware that our office does NOT offer payment plans? If you want/need a payment plan we recommend using Advance Care Cards. *

Yes, I understand that your office does NOT offer payment plans No
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