Become A Patient

Here at The Parkinson’s Plan, we are committed to helping you achieve your healthcare goals. Once you submit your application, we will contact you within 1-2 business days and schedule a 20-minute complimentary consultation via Zoom. This appointment is to learn more about each other and determine if we are a good fit to work together.

Please fill out the form below in detail. Thank you, and we look forward to starting this journey with you!

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Name*

Date of Birth*

Gender*

Email*

Cell Phone*

Home Phone*

Billing Address*

What are your current medical concerns?

What have you tried to improve your medical condition?

Do you have any history of trauma or extreme stress?

What do you think contributed to the cause of your medical concerns?

What do you believe it takes to improve your symptoms and health?

Do you currently have any bad habits? (This can include but is not limited to sugar, soda/pop alcohol, recreational drugs, cigarettes)

Are you willing to make significant lifestyle changes?

Yes

What, if anything, are you NOT willing to change?

Do you struggle to change or improve your habits?

Yes

Do you have a support system?

Yes

What are your expectations in working with The Parkinson’s Plan?

Is there anything else that is important to know about you?

What are your expectations in working with The Parkinson’s Plan?

Become A Patient

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