New Patients

New Patients: 815-271-7300

Existing Patients

Existing Patients: 815-271-7300

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.

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.

How many different providers have you worked with on these issues?

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

What has stopped you from reaching your goals?

What would you be able to accomplish if you were feeling your best?

Vitality Renewal does not contract with any health insurance companies. Are you ready and able, both emotionally and financially, to invest in your health? *

Yes

No

Are you an Illinois resident? *

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

By checking this box you are acknowledging that the meeting may be recorded.

I acknowledge the meeting may be recorded.

By applying for a discovery call, you are acknowledging that you will be added to my email list. *

I understand that I will be added to your email list and can unsubscribe at any time.

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

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