New Client Booking Request Form-Dr. Dias
Thank you for your interest in a natural integrative health! Spots limited, therefore we are only able to help a few clients at a time. This is not insurance-based care. Insurance care is scheduled with Living Pure Chiropractic 623.572.4476. 

Please complete this brief form. It allows us to receive a little background on your health concerns and expectations. Once we receive this, we will contact you! By submitting,  you consent to receiving Dr. Dias' info updates and notifications for upcoming availability. We will not sell your information. You can change preferences or unsubscribe at any time.

Thank you, kindly.



Please answer the questions below to the best of your ability and within your comfort level.
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Email *
Today's Date *
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Please enter your first name below and last initial *
Your phone number: *
Gender *
Your Age Range
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How satisfied are you with your current health status? *
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I am interested in (Check all that apply) *
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How long have you been experiencing your primary health concern? *
What are your goals? *
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Which other services have you received in the past or currently receiving?
Past
Currently
Chiropractic
Naturopathic
Homeopathic
Nutritionist/Dietician
Health Coach
Craniosacral Therapy
Functional Medicine
Ayurveda
Detox/Weight Loss Clinics
Taking Supplements
Personal Trainer
Clear selection
How long you believe it may take you to achieve these goals? *
Your readiness for a change. *
Natural medicine, functional medicine, chiropractic all require a team effort between the practitioner and client. On a scale of 1 to 10, (10 meaning you are 100% in), please indicate how ready you are to make necessary changes to your diet and lifestyle:
Not ready
Absolutely! I am more than ready!
Attestation (Please type your first name and last initial to attest the answers above are true to the best of your knowledge) *
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