Application for Consultation
Thank you for filling out this form. Please fill out only what you feel comfortable answering. This form is meant to help us both maximize our time together on our 15 minute, no-cost Introductory Call. Only I will be reviewing this form, and everything you take the time to answer will be read carefully, and will help to start you on the path towards optimal health. After reviewing your answers, I will be in contact within 72 hours in order to set up an Introductory Call.

Your answers will be stored in a HIPAA-compliant secure database powered by G-Suite.

Warmly,
Casey Means, MD

What is your name? *
Your answer
How did you hear about my practice?
What can I help you with? Specifically, what symptoms or conditions inspired you to reach out to me?
Your answer
How has prior treatment of these conditions fallen short? In your opinion, what is missing from your current treatment regimen?
Your answer
What motivates you to want to get to the "root cause" of your concerns?
Your answer
What have been your greatest challenges in maintaining optimal health in your life? What are the barriers? (ie, Information? Support? Motivation?)
Your answer
Are you willing to fill out a detailed, 3 day food journal prior to your first consultation with me?
How motivated are you to make changes to your diet if these were recommended in order to improve your health?
Not enthused
Ready to change, just need direction!
Do you have a established relationship with a Primary Care Provider? (this is required prior to consultation, as Casey Means, MD does NOT function as a Primary Care Provider).
What is your email address? *
Your answer
What is your phone number?
Your answer
May I use the above email address to contact you about scheduling an Introductory Call?
Submit
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