Contact Us New Client Information This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page: (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020). Important: Delete this tip before you publish the form.Name(Required) First Last Email(Required) Today's Date: MM slash DD slash YYYY Date of Birth: MM slash DD slash YYYY Gender Male Female Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneHow did you hear about us?What do you know about what we do?Are you interested in an appointment for yourself? ☐ Y or N ☐ If not, for whom?Do you have a medical diagnosis? Y ☐ N ☐ If so, what is it?What is your biggest challenge?What Physical Scars Do You Have On Your Body (Stiches, Surgeries, Operations, Etc?)(Required)Do you currently or have you ever had amalgam fillings?Do you or have you ever had root canals or implants? If so, please specify which tooth or teeth if you're aware.Do you have or do you use any dental appliances? If so, please specify.Do you or have you ever had breast implants?Do you or have you ever had Botox injections?Do you feel you need lifestyle or nutrition support? If so, please elaborate.Do you have lab work that you would like to review?Where do you see yourself 6 months – 1 year from now if you were feeling healthy?What else have you tried? Be specific!How would your life change?Would you like to be added to our newsletter? Yes No Any additional notes that our practitioner should know when calling you:CAPTCHA