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.
Name of Individual Seeking Consultation: *
Patient - First and Last Name: *
Relation to the Patient: *
Required
How did you hear about us/referred by? *
Patient Age: *
Phone Number: *
Email: *
City and State: *
Diagnosis Given to the Patient: *
Required
Please check off any symptoms that apply to the patient: *
Required
Additional History *
Throughout the week, what timings are you available for your consultation? *
Required
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