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NEUCOA Information Request Form
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Email
*
Your email
I Agree and Understand that this Virtual Consultation/meeting is for INFORMATIONAL purposes only and NOT meant to diagnosis or treat any known medical condition(s).
Type Patient/Parent or Guardian's first and last name below:
*
Your answer
Phone number (Area and/or Country code if outside of US)
*
Your answer
Please check your email JUNK folder for a response to your request for a consultation.
Last Name
*
Your answer
Your First Name
*
Your answer
Patient's full name
Your answer
Patient Type
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Adult (over 18 years old)
Pediatric
Patient's age
Your answer
Where do you currently reside/live? City, State, and
Country if living outside of the USA
Your answer
Known medical diagnosis or concern? Autism, Depression, PTSD, etc.
Your answer
Your Meeting Availability- What day of the week and morning or afternoon time? (Our hours are 9:00 a.m.-4:00 p.m. M-F).
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Your answer
How many people will be attending?
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Your answer
How did you hear about us?
*
Choose
YouTube
Friend/family/co-worker
Internet search
Facebook
TV/radio/podcast
Medical provider or Counselor
Wave Neuroscience/BTC website
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