New Patient Application

Begin your healing journey with the West Clinic! First, we want to get to know you. Complete the questions below. We use this information to make sure our clinic is the right fit for you and your needs.

After reviewing, our Patient Care Coordinator will contact you to answer questions, discuss your treatment options, and next steps.

We look forward to welcoming you to the West Clinic!

Introduce Yourself

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is your number one goal when it comes to improving your health?

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)

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?

Which of the following are you interested in?

How did you hear about us?

How serious are you about working with the West Clinic to get to the root cause of your health concerns?

Type a question