Consultation Request Form

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Please fill out the following information to schedule your free consultation with the POTS Treatment Center.

Once we receive your completed form, you will receive a call or email from us to set up your consultation appointment within 24 hours of your submission. Please respond promptly as the slots fill up quick!

PLEASE have your guardian/spouse with you on the call if they are going to be helping you with your decision making in regards to moving forward with the program.

The phone consultation will be approximately 30 minutes with Dr. Kyprianou or our program coordinator in which they will discuss the treatment options and address any POTS related questions you may have.

Name of Individual Seeking Consultation: *

Patient - First and Last Name: *

Relation to the Patient: *

For myself

For a family member

For a friend

Other:

Required

How did you hear about us/referred by? *

Patient Age: *

Phone Number: *

Email: *

City and State: *

Diagnosis Given to the Patient: *

POTS

Dysautonomia Disorder

No formal diagnosis, but suspected POTS

Other:

Required

Please check off any symptoms that apply to the patient: *

Headaches/ Migraines

Tachycardia (fast heartbeat)

Nausea

Dizziness/ Lightheadedness

Fatigue

Fainting or Near Fainting Episodes

Seizures

Brain Fog

Tunnel Vision (narrowed eyesight)

Thermoregulation (overheating/ cold sensitivity)

High/ Low Blood Pressure

Gastrointestinal Issues

Insomnia

Other:

Required

Additional History *

Throughout the week, what timings are you available for your consultation? *

Mornings

Afternoons

All day

Required

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