EmailMeForm
Complimentary Consultation Request Form
Your information will be kept strictly confidential and will not be shared under any circumstances without your written consent.
Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Email
*
Phone
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Address
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Address Line 2
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Country / Region
Profile Information
Body Weight (lbs)
*
Tick Exposure/Infection Date
MM
/
DD
/
YYYY
(If unsure, please use your best estimation)
Tick Exposure
Confirmed Tick Bite
Confirmed Circular Rash
Borrelia Test Result(s)
Positive
Negative
Inconclusive
Babesia Test Result(s)
Positive
Negative
Inconclusive
Bartonella Test Result(s)
Positive
Negative
Inconclusive
Most Recent CD-57 Result
Please leave blank if you were not tested.
Date of most recent CD-57 test
MM
/
DD
/
YYYY
Please use your best estimation
Additional Information about Lab Tests and Presence of Co-infections
Leave blank if there's no additional information to add
Are you currently taking antibiotics?
Yes
No
If no, have you ever taken antibiotics in the past?
Yes
No
Did you experience a Herxeimer's reaction?
Yes
No
How long was the antibiotics treatment course?
Please leave blank if you did not receive treatment
Did you experience any improvement with antibiotics treatment?
Yes
No
Please leave blank if you did not receive treatment
Please list the medications or supplements you are currently taking for treatment
Symptoms Information
General Sx
Severe Fatigue/Weakness
Night Sweats
Fevers
Chills
Shortness of Breath/Air Hunger
Please check if you experience any of these symptoms
Mental/Emotional Sx
Mental "Fog"/Difficulty Focusing
Depression/Anxiety/Irritability
Insomnia
Difficulty with Speech, Reading or Writing
Low libido
Please check if you experience any of these symptoms
Systemic Sx
Persistent Joint/Muscle Pains
Tingling, Numbness in the limbs
Coldness in the limbs
Facial Paralysis (Bell's Palsy)
Light/Noise Sensitivity
Tinnitus (ringing in the ears)
Poor Balance
Nausea/Vomiting
Heart Palpitations
Constipation
Diarrhea
Seizures/Convulsions
Muscle Spasms
Please check if you experience any of these symptoms
Please provide any additional notes about your symptoms you'd like to include
Leave blank if there's no additional information to add