Patient Application

Welcome to my patient application! If you are interested in becoming a client, please fill out the application below Once you complete the application you will be able to select an appointment time that is convenient with your schedule.

Fill out the form and click submit!

Is this application for self or child?

Your Name

Child's Name (if applicable)

Age of Child (if applicable)

Your birthday (if applicable)

Phone Number

How do you hear about Restore To Thrive?

If applicable, are you currently breastfeeding?

What is your biggest struggle when it comes to your child’s health?

Have you already tried any approaches to improve their health? If so, what has or hasn’t worked?

What are your top 3 goals for your child’s health?

Is there anything else you'd like me to know about your family’s health journey?

Are you also looking for support with your own health and wellness?

My wellness program is a 4-figure investment. Are you willing to make the monetary investment?

On a scale of 1-10, how committed are you to making lifestyle changes for your family’s health?

Form submission[]

Patient Application

Fill out the form and click submit!

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