Schedule an Appointment

Please fill out the fields in the form below and click submit.

First Name

Contact Number

Please enter the phone number where we may text or call you

Where is your pain or what illness are you experiencing

Please tell us a little bit about your current pain/injury/illness

Please list any allergies to medications

Please list any medications you currently take

Do you use tobacco products?Yes, current useNo, neverNo, former use

How many drinks of alcohol to you have in a typical week

Selected Value: 0

Please select any of the following conditions you have been diagnosed with

• Arthritis
• Kidney disease
• Liver disease
• Bleeding disorder
• Heart disease
• Diabetes Type 1 or 2
• Hypertension
• High cholesterol
• Heart attack or stroke
• Anemia
• Thyroid disease
• Anxiety
• Depression
• Cancer

Other

Please use this field to add any conditions you have been diagnosed with that are not included in the list above

Are you currently experiencing any of the following symptoms

• Fever
• Fatigue
• Pain
• Vision changes/loss
• Sore throat
• Cough
• Wheezing
• Chest pain
• Difficulty breathing
• Heart palpitations
• Nausea
• Vomiting
• Diarrhea
• Constipation
• Blood in your stool
• Blood in your urine
• Pain/burning with urination
• Weakness
• Numbness/tingling
• None of the above

Please select all that apply

Submit

If preferred – please feel free to text or call at 480.648.3033 to schedule an appointment

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