New Patient Consultation Intake Form
Your information will be kept strictly confidential and will not be shared under any circumstances without your written consent.
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  • For LYME DISEASE and co-infection(s)

    Please leave fields empty if they are irrelevant to your condition
  • / /
    (If unsure, please use your best estimation)
  • Please leave blank if you were not tested.
  • / /
    Please use your best estimation
  • Leave blank if there's no additional information to add
  • Please leave blank if you did not receive treatment
  • Please leave blank if you did not receive treatment
  • Symptoms Information

  • Please check if you experience any of these symptoms
  • Please check if you experience any of these symptoms
  • Please check if you experience any of these symptoms
  • Leave blank if there's no additional information to add
  • Your information will be kept strictly confidential and will not be shared under any circumstances.