Initial Phone Consultation Form
This form helps to get you to think about your current health situation and helps us to see if you are ready for our approach. We will review this information and give you a call if we think you are a good fit for our practice.
Email address *
Holistic ICON
Name *
Your answer
Phone Number *
Your answer
Email *
Your answer
Date of birth *
What are the main issues you are looking to resolve? *
Your answer
How long have you been struggling with these issues? *
Thinking about your current health costs, how much are you currently spending per year? *
$0 - $100
$100 - $200
$200 - $300
$300 - $400
$400 - $500
$500 or more
Doctor's Visits
Over the counter medications
Prescription medications
Lab testing
Holistic / Natural Doctors
Do you have the time to take care of your health issues? *
Would you be willing to invest $1000 in your health? *
Have you reviewed our website, *
(Specifically our Programs)
When is the best time to try to contact you?
Your answer
Thank you for your time filling in this form. We will review the results and give you a call if we think you are a good fit for our practice.
If you haven't already, please take a look at our website ( and review our programs (
Thank you for your interest in Holistic ICON!
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