Complementary Evaluation Survey

Take the next step in your healing journey! Complete your information below to request your complimentary evaluation with our Patient Care Coordinator.

We’ll answer your questions, explore your options, and help you schedule your first appointment.
Introduce Yourself*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your number one goal when it comes to improving your health?*

Have more energyGet better sleepImprove lifestyle and eating habitsDecrease pain levelImprove digestion and nutrient absorptionGeneral HealthOther
If other, please describe.
Please describe your current health problems, diagnosis, or symptoms.*
Which of the following best describes the types of treatments or interventions you’ve tried in the past? (Select all that apply)*

Traditional medical approach (e.g., antibiotics, prescriptions from an MD)DIY or self-guided (e.g., online research, supplements without provider guidance)Holistic or integrative approach (e.g., naturopathic care, acupuncture, herbal protocols)NoneOther
If other, please explain.
Please provide a summary of interventions or treatments you have tried in the past.*
Are you willing to invest in your health knowing our services are not covered by insurance?*

YesNo, I'm not willing to investI'm not sure yet
Which of the following are you interested in?*

In-office TreatmentsVirtual CareBothI'm not sure yet
How did you hear about us?*

Referral from Friend or FamilyGoogle SearchFacebookYouTubeInstagramTikTokOther
How serious are you about working with the West Clinic to get to the root cause of your health concerns?*

Just looking for informationModerately serious100% committed. Let's get started!
Type a question
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