NOTE

This is a very detailed form, which takes an average of 20-40 minutes to fill out; so please be sure you have adequate time set aside to completely fill it out prior to your consultation time slot. If you are unable to complete this form prior to any appointment which requires its completion, your appointment may need to be rescheduled; Please call at least 24 hours prior to your appointment if you are unable to complete this form.

Should you need to step away for a bit and return to complete your form, we have included a "progress save" option. Be sure to click the "Save" button (found at the bottom of any page) before you close out of this window or step away from your computer or mobile device. Once you click "Save", you will be prompted to either sign up for a Jotform account or "Skip Create an Account". Select "SKIP" to be given the option to have your progress emailed to the account of your choice, or instantly receive a link.

While we know it takes time to completely fill our form out, please know that it is necessary to ensure that we have as much information as possible to evaluate your health needs / concerns. We appreciate your patience and time.

A DrL Integrative Medicine ("Counselor") health evaluation is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

Health-related information changes frequently, and, therefore, a Counselor health evaluation may be become outdated, if regular consultations are not scheduled. We do not assume any liability for the information given during a consultation and make no warranties, nor express or implied representations, regarding the accuracy, completeness, timeliness, or usefulness of any information referenced during a consultation.

Results may vary from patient to patient. No nutraceutical, diet, or health advice will be given until we receive all information that our doctor(s) require (incl, but not limited to, the completion of our Patient Form, approval from your PHP, etc.). Any review or material that could be regarded as a testimonial or endorsement does not constitute a guarantee, warranty, or prediction regarding the outcome of any consultation. 

You must agree to the statement above (by signing below) before you may move to the next section of this form.

The following sections ask a lot of personal information which some may feel uncomfortable in answering. But, your honesty in answering the following questions is critical in ensuring that our doctors are best equipped to evaluate your needs / concerns, so that they may provide you with an accurate, suggested regimen, during your consultation.

In addition to a strict Patient-Practioner Privacy Protocol, all of our patient and office documents are stored in an isolated, special cloud storage location; With all patient information encrypted the instant this form is submitted to our cloud storage. Only those authorized to access our cloud storage will ever be able to view the information you submit through this form.

This concludes our Patient Form.

Thank you for your honesty, time, and patience in filling out this form.

Upon submission of this form, you will be automatically redirected back to our website.