Let's find out if we're a great fit for each other
Please fill out your information below and we'll be happy to see how we may best serve you!
What's your first name?
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What's your last name?
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What's your best phone number?
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What's your date of birth?
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What's your best email?
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What are you the top health concerns that you would like us to help you overcome?
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Why is this goal important to you, and what do you think is stopping you from accomplishing it?
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If you were to wake up tomorrow without this challenge, how would your life be different?*
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Do you consider yourself coachable?
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No
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Do you have a supportive spouse, significant other, or friend to support your personal goals?
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Yes
No
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What are the characteristics that you value most in a professional partnership?
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Who else have you worked with?
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Functional Medicine Practitioner
Medical Doctor/Osteopathic Doctor
Medical Specialist
Naturopathic Doctor
Traditional Chinese Medicine
Nutritionist/Dietician
Personal Trainer
Chiropractor
Personal Development Coach
Other
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If Other:
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What functional lab testing have you done previously?
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Functional Stool Testing
Organic Acids Testing
Adrenal/Cortisol Testing
Genetic or Genomic Testing
Hormone Testing
Food Sensitivity Testing
Heavy Metal Testing
None
Other
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If Other:
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Considering your past treatments, what would you like to improve or do differently moving forward?
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Are you willing to do what's necessary to reclaim your health? (This may include dietary modifications, functional lab testing, lifestyle and environmental modifications, etc)
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Yes
No
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How did you hear about PIH?
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In your opinion, what makes you a good fit for our practice?
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