CT Scan Information Request
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
*
-
Area Code
Phone Number
Whatsapp/Telegram no. (if outside N.America)
*
Timezone
*
Gender
*
Please Select
Male
Female
Age
*
Date of birth
*
Do you have a brain CT scan without contrast?
*
Yes
No
Yes I have sent it via WeTransfer
I have sent it via telegram to Andi
I am waiting to have my scan
I have had my scan but am waiting for the file.
Date scan sent, if already sent
Would you like to cap the consultation at 1 hour? (A further appointment can be scheduled)
*
If you have someone (other than Andi) joining your CT reading please list their name, email and timezone, if different from yours.
How did you hear about us?
*
What are your expectations for this consult?
*
Hormone Status (answer if you are a female - Cycling, Post Menopausal, on Birth Control, etc.) Put N/A if you are a male.
*
Are you on any hormone-based medications?
*
Handedness
*
What are the 3 most important issues you want to discuss?
*
Anything else you would like us to know?
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