Consultation Request Form
Please fill out the following information to schedule your free consultation with the POTS Treatment Center.
Once we receive your completed form, you will receive a call or email from us to set up your consultation appointment within 24 hours of your submission. Please respond promptly as the slots fill up quick!
PLEASE have your guardian/spouse with you on the call if they are going to be helping you with your decision making in regards to moving forward with the program.
The phone consultation will be approximately 30 minutes with Dr. Kyprianou or our program coordinator in which they will discuss the treatment options and address any POTS related questions you may have.
* Required
Name of Individual Seeking Consultation:
*
Your answer
Patient - First and Last Name:
*
Your answer
Relation to the Patient:
*
For myself
For a family member
For a friend
Other:
Required
How did you hear about us/referred by?
*
Your answer
Patient Age:
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
City and State:
*
Your answer
Diagnosis Given to the Patient:
*
POTS
Dysautonomia Disorder
No formal diagnosis, but suspected POTS
Other:
Required
Please check off any symptoms that apply to the patient:
*
Headaches/ Migraines
Tachycardia (fast heartbeat)
Nausea
Dizziness/ Lightheadedness
Fatigue
Fainting or Near Fainting Episodes
Seizures
Brain Fog
Tunnel Vision (narrowed eyesight)
Thermoregulation (overheating/ cold sensitivity)
High/ Low Blood Pressure
Gastrointestinal Issues
Insomnia
Other:
Required
Additional History
*
Your answer
Throughout the week, what timings are you available for your consultation?
*
Mornings
Afternoons
All day
Required
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