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Getting Acquainted Form
Thank you for booking your consultation. Please complete and submit the following form to help me prepare for our meeting.

I look forward to meeting you.

Your Name *
Your answer
Date and Time of Your Consultation *
Your answer
How can I help you? *
Your answer
How motivated are you to achieve your goal (10 = Highly Motivated) *
Your answer
What other things have you done to try and solve this problem? *
Your answer
Do you have a pacemaker? *
Do you have a heart condition? *
Have you had heart surgery? *
Do you have a psychiatric issue, i.e., severe depression, bi-polar, schizophrenia? *
If you answered yes please elaborate
Your answer
Do you have a epilepsy? *
Do you have a concussion you have not been medically cleared from? *
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