Becoming A Client | Vitality Renewal

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NEW PATIENT APPLICATION

At Vitality Renewal Functional Medicine, we want to PARTNER with you on your journey to optimal health. We are here for ONE reason–to help you achieve your health goals so you can live the life you were meant to live—with ENERGY and FOCUS!

We only accept clients into the practice who we believe will be successful– the first step is the application below.

Please answer the following questions with 100% honesty so that we can learn more about you. While we would love to work with everyone, it is simply not possible. We limit acceptance of new patients to only those who are fully committed to restoring their health.

Screening Tool

Name

First Name

Last Name

Email *

Phone *

How old are you?

How would you rate your physical energy level? (1 is poor, 10 is awesome)

How would you rate your mental clarity/ ability to focus & create? (1-10)

How would you rate your emotional well-being? (1-10)

What is your main issue you would like help with?

Tell us about your physical symptoms and how they affect your life.

What has stopped you from reaching your goals?

Did you have any success with these other practitioners? If so, what were your wins?

Are you an IL resident?

Yes

Are you able to come to Crystal Lake, Illinois for your first visit?

Yes

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

If you are human, leave this field blank.

NEW PATIENT APPLICATION

We only accept clients into the practice who we believe will be successful– the first step is the application below.

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