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New Patient Form - Injection or IV
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* Indicates required question
Name
*
Your answer
Last Name
*
Your answer
Street Address
*
Your answer
City, State, Zip
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
Your answer
Age
*
Your answer
Gender
*
Female
Male
Other:
Occupation
Your answer
Email Address
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
How did you hear about us?
*
Internet
Social Media
Drive By
Friend
Other:
If referred by a friend, leave their name so we can show appreciation!
Your answer
What are your main concerns? (Please check all that apply)
*
Fatigue or low energy
Stress
Poor diet due to busy life
Brain fog or trouble concentrating
Low mood or depression
Headaches or migraines
Weight gain or difficulty losing weight
Slow metabolism
Asthma and allergies
Recent surgical procedure
Recent illness
Cold or flu symptoms
Facial wrinkles or fine lines
Dull or dry skin
Malabsorption issues
Other:
Required
Which statements best describe why you are here today?
*
I want to have more energy and feel better overall.
I want to do everything I can to nourish my body
I want to do everything I can to enhance my weight loss efforts
I want to prevent getting sick
I want to recover quickly from my surgery or illness
I want to slow the aging process
I want to feel and look younger
I want to have smoother, brighter and more vibrant skin
I want to cleanse my body of toxins
Other:
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