Request for General Consultation
Please fill out the following information. The cost of consultation is $60.00 via Skype/telephone. Length of the consultation is up to one hour. Please forward, within 48 hours, any pertinent documents (doctors' opinions, analyses, etc., if available) for the last 6 months pertaining to the condition for which the consultation is requested. They can be uploaded at the bottom of this form or emailed to email@example.com. They can also be faxed to 661-459-2329 (use country code 1 if faxing from outside of the United States/Canada.)
After completing this request, click "SUBMIT". You will be transferred to the PayPal site to complete the payment. We will contact you soon.
Thank you for entrusting us with your health needs.
World-Wide Naturopathic Health Service
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IMPORTANT NOTICE: There is no obligation of any kind whatsoever to buy any naturopathic formulations, remedies, or supplements from our dispensary. For more information go to http://www.kulisz.com/practice/office-fees/
First and last name
New or established patient?
In inches or centimeters
Select inches or centimeters
Round up to full number
Select pounds or kilos
Example: 130/80. Enter 999/99 if unknown.
Cholesterol (Enter 999 in all fields if unknown)
How are you?
Please tell us how is your overall health comparing to previous assessment.
No hyphens, no spaces. Non US and Canadian filers, please include country code.
Family or friend
In the next field "Other", please tell us how did you find us if not referred by Dr. Kulisz or Dr. Dahlmann.
Primary health concerns or reason for consultation
If none, write 'None"
If none, write "None"
Medications you are currently taking
If none, write "None"
Are you pregnant?
Do you use tobacco?
Are you at risk for falls or falling injuries?
Write here questions you want ask and provide additional information that you feel is pertinent to your health. If none, type "None"
Upload additional information (drs opinions, analyses reports, x-rays, etc...) that you think may be of importance.
Please enter the text from the image: