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NOTE: Please make sure that all typed information fits within the boxes provided on the form.
COMPLEX CLINICAL: For those with complex clinical diagnoses that simply cannot fit within the boxes on the form, please either “drag and drop” a single-page document to the end of the form before clicking “submit”, or email/fax it to our office, listing:
- all physical and/or mental health conditions that you have been diagnosed with
- the date of diagnosis of each condition
- all physician-diagnosed allergies (i.e., by an MD) that you have
- list all medications and their dosages
- list all nutritional supplements and their dosages