Work With Dr. Rak — Patient Application
Apply to become a patient at RAK Your Life with Dr. Rak Jotwani. Please complete all relevant sections to help us understand your health goals and background.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
State of Residence
*
Please Select
California
New York
Texas
Florida
Washington
Oregon
Colorado
Illinois
Virginia
Georgia
Massachusetts
Arizona
Other
Primary health concerns and goals
Current diagnoses
Current medications
Current diet quality
Please Select
Mostly whole foods
Mixed
Mostly processed
Not sure
Activity level
Please Select
Very active 4+ days/week
Moderately active 2-3 days/week
Lightly active
Mostly sedentary
Sleep quality
Please Select
Great 7-9 hours
Fair
Poor
Stress level
Please Select
Low
Moderate
High
Very high
What brings you to RAK Your Life now?
*
What does success look like in 6 months?
*
Have you worked with a lifestyle medicine physician before?
Yes
No
How did you hear about Dr. Rak?
Please Select
LinkedIn
Podcast
Newsletter
Friend or family
Google
Other
Any questions for Dr. Rak?
Submit My Application
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