Request a Call - Bayani Health

1

First name* This field is required.

2

Email address* This field is required.We’ll use this only to follow up about scheduling.

3

Phone number* This field is required.Used for appointment reminders for your scheduled call with our physician.

4

What state do you currently live in?* This field is required.

5

What are you hoping to get help with right now?* This field is required.

Alcohol use.

Opioid use (prescription pain medications or heroin/fentanyl).

Both alcohol and opioids.

I'm not sure yet. I'd like to talk it through with the doctor.

6

How long has this been a concern for you?* This field is required.

Less than six months.

Six to twelve months.

More than a year.

On and off for several years.

7

Are you currently taking any medications related to alcohol or opioid use?* This field is required.

Yes.

No.

Not sure.

8

Do any of the following apply to you right now?* This field is required.If you’re in immediate danger or thinking about harming yourself, please call 911 without delay or go to the nearest emergency room. You may also call or text 988 for the Suicide & Crisis Lifeline.

I've had difficult withdrawal symptoms recently.

I've had a recent overdose.

I've had thoughts of harming myself.

I'd rather talk about this during the call.

No, none of these apply.

9

If you’re in immediate danger or thinking about harming yourself, please call 911 without delay or go to the nearest emergency room. You may also call or text 988 for the Suicide & Crisis Lifeline.

10

Bayani Health & Wellness is a fully online medical practice, with treatment programs that include medication, nutrition, and movement support. Does this sound like what you're looking for?* This field is required.

Yes, that sounds right.

Maybe. I'd like to learn more.

I'm not sure yet.

11

Are you comfortable with secure telehealth (video) visits?* This field is required.

Yes.

I think so.

No.

12

What’s your main goal for the free physician call?For example: learning about treatment options, whether medication might help, or whether Bayani is a good fit for you

13

If Bayani Health & Wellness feels like a good fit, how soon are you hoping to start care?

As soon as possible.

Within the next few weeks.

I'm just gathering information right now.

14

Consent* This field is required.

I understand this introductory call is not a medical visit and does not establish a doctor–patient relationship.

I understand that Bayani Health does not provide general medical care or prescriptions outside of addiction treatment. and is unable to prescribe medications without an established physician-patient relationship.

15

Consent* This field is required.

I understand this introductory call is not a medical visit and does not establish a doctor–patient relationship.

I understand that Bayani Health does not provide general medical care or prescriptions outside of those related to addiction treatment.