Important Instructions:

You must complete the entire form. This form is embedded so you will need to scroll  WITHIN the blue area or text to see additional questions.

If you are having trouble completing the form on this page try clicking here to view it in a different window.

Keep scrolling within the blue area above until you complete all the questions! There are several sections and you will need to click a "Next" button for each section. You will know you are done when you click the "Submit" button at the end of the form.

You should see a message that says, "Your intake form responses have been successfully submitted!"

If you need to fill out an additional form for another family member there will be an option to submit another response.

If you are having trouble completing the form on this page try clicking here to view it in a different window.

If that still doesn't work please send us an email at

Thank you!

You understand and acknowledge that all users of this website are responsible for their own medical care, treatment, and oversight. All of the content provided on the website, including text, treatments, dosages, outcomes, charts, profiles, graphics, photographs, images, advice, messages, and forum postings, are for informational purposes only and DOES NOT CONSTITUTE THE PROVIDING OF MEDICAL ADVICE and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment.


The content is not intended to establish a standard of care to be followed by a user of the website. You understand and acknowledge that you should always seek the advice of your physician or other qualified health providers with any questions or concerns you may have regarding your health. You also understand and acknowledge that you should never disregard or delay seeking medical advice relating to treatment or standard of care because of information contained in or transmitted through the website.


Medical information changes constantly. Therefore the information on this website or on the linked websites should not be considered current, complete or exhaustive, nor should you rely on such information to recommend a course of treatment for you or any other individual. Reliance on any information provided on this website or any linked websites is solely at your own risk.

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