Neural Wellness Application

Nombre

Apellidos

Correo electrónico

Número de teléfono

City, State, Zip Code

Date of Birth

Health Concerns - Which of the following do you need support with? Check ALL that apply.

Dependencies

Amphetamines, Meth, Cocaine & Stimulants
Heroin, Opiates, Morph, Subox, Meth & Tobacco
Pain Killers, Marijuana, Alcohol & Benzos
Barbiturates, Sedatives & Tranquilizers
Pornography, Gaming, Gambling & Sexual

Physical

Memory Enchancement, Focus, Concentration
Insomnia, Sleep Apnea, Fibromyalgia, Chronic Fatigue, Chronic Pain
Headaches, Migraine, Sinus
Weight Control, Hormone Balance
Autism, Alzheimers, Parkinson's Disease
Muscular Dystrophy, Multiple Sclerosis

Emotional

Is there anything else not listed above that you'd like support with?

Health History - Please list any current medications and supplements

Health Diagnosis - Please share any relevant medical history, diagnoses, or conditions

Pregnancy Status

I am not pregnant
I am pregnant
I am breastfeeding

Do you have any implants of any kind?

Device Safety Screening. Please answer honestly. Your safety is our priority.

Are you currently pregnant or breastfeeding?

Yes
No

Do you have implanted electronic devices pacemaker, cochlear implant, or intrathecal pump?

Yes
No

Do you have a history of epilepsy or seizures?

Yes
No

Are you prone to seizures triggered by flashing lights?

Yes
No

Do you have high blood pressure (systolic ≥ 160 or diastolic ≥ 110)?

Yes
No

Do you have severe heart or kidney conditions?

Yes
No

Do you have metallic implants near the head or treatment area?

Yes
No

Are you under 12 years old?

Yes
No

Have you had a stroke or heart attack within the last 6 months?

Yes
No

Do you consume alcohol or recreational drugs regularly?

Yes
No

Do you have untreated severe depression or bipolar disorder?

Yes
No

If you answered YES to any above please explain:

I confirm all answers are accurate and I understand that inaccurate answers may affect my safety and eligibility for certain services.

What type of service are you interested in?

In-Clinic Appointments
Virtual Sessions (available worldwide)
House Call (non-emergency personal wellness support, additional travel fee applies)
Not Sure Yet, Need Guidance

regularly? Health you

What is your main health goal?

Have you tried other treatments or approaches? If, so please explain below.

How soon are you looking to see results?

Immediately - I need help now.
Within 1 month
Within 3 monthss
I understand healing takes time and I am committed to the process

¿Cómo se enteró de nosotros?

What days are you generally available?

What time of day works best for you?

Morning 8am-12pm
Afternoon 12pm-4pm
Evening 4pm-7pm
Flexible - Any Time

What's your investment range for wellness support? Healing is an investment in your future. Understanding your budget helps us design a protocol that works for your situation.

Are you ready to commit to showing up consistently?

What best describes what you're looking for right now?

I'm ready to commit to a full protocol (minimum 6-8 weeks)
I'm interested in a single session or trial package first
I'd like a wellness evaluation or consultation only
I'm interested in lab reviews or functional lab testing only
I'm not sure yet, I need guidance on where to start
I just want to learn more before committing

How would you like to move forward?

I'd like an evaluation first to help me figure out what I need (consultation + optional labs)
I know what I want let's get started on a protocol
I'm interested in lab testing only, I want to understand my health better
I just want to talk to Susan first, I have questions before committing
Not sure yet, I need guidance

Is thre anything else you would like us to know before your consultation?