Cassandra's Holistic Appointment Request

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We provide personalized and tailored holistic solutions, integrating comprehensive pain management and wellness therapies to address your unique medical requirements.

(By completing this form you are consenting to provide your personal health information to us)

First Name *

Last Name *

Date of Birth *

YYYY

Your Address

Best phone number (mobile phone preferred) *

Your email *

Small write up with your reasons for this consultation

Do you agree to pay for my services at the time of your visit? *

Yes

Required

I offer following holistic treatment options

(click all that apply)

Consultation ($300 per one hour session)

Assessment ($150 per half hour session)

Comprehensive Program ($1500 12 half hour treatment sessions)

One on one therapy - stretching, strengthening, taping, exercise etc., ($2 per minute)

CBD products like gels, creams, tinctures and ointments ($50)

Vitamin IV Infusions - for health and wellness ($250)

Plasma Rich Protein Injection - for natural pain relief ($500)

Stem Cell Injection- for natural pain relief ($3000)

Other:

Please choose your location for appointment: *

Dover (240 Beiser Blvd)

Lewes (33664 Suite 201 Bayview Medical Dr)

Wilmington (390 Mitch Road)

Required

Thank you for your interest in Holistic Care!

I will confirm your appointment in 3-5 days.

Urgent messages, call at (302) 212-4845.

For additional visit our practice website: www.painrehab.net

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