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New Patient Application

Interested in working with Dr. Sara? Please fill out this application to get started.

Click the button below to start.

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Question 1 of 15

What the primary reason for seeking consultation with Dr.Sara?

Question 2 of 15

How long has this topic of concern been on your mind?

A

Less than a month

B

Less than 6 months

C

6 mos- 1 yr

D

More than 1 yr

Question 3 of 15

Please describe you current level of physical activity

Question 4 of 15

How you would describe your current nutrition & dietary habits?

Question 5 of 15

Please indicate your level of commitment to self-care and previous treatment plans you may have engaged in with other clinicians

A

None

B

Some, when I had time

C

Lots, I always make time

Question 6 of 15

Do You Smoke?

A

Yes

B

No

Question 7 of 15

Do You Drink Alcohol?

A

Yes

B

No

Question 8 of 15

How motivated are you to get better?

A

Not motivated at this time

B

Somewhat motivated

C

Moderately motivated, I'm ready to step it up

D

Highly motivated, I'll do whatever it takes

Question 9 of 15

Please indicate behaviors you are UNWILLING to change 

(Select all that apply)
A

Intensity of physical activity &/or style of exercise

B

Nutrition & dietary habits

C

Alcohol intake

D

Smoking

E

Lifestyle & behaviors like sleep hygiene, morning routine, water intake etc.

F

other

Question 10 of 15

How much time do you have to commit to your health and wellness?

A

I don't have time

B

I'm really busy, but I can make time

C

I'm busy, but I will make time

D

I have plenty of time

Question 11 of 15

Please indicate your ability to financially invest in your health and wellness. *This helps Dr. Sara guide you towards solutions that align your needs.

A

I don't have the budget

B

Resources are limited, but I am willing to make a budget

C

I have the budget

Question 12 of 15

How did you hear about Dr. Sara & Advantage Body Solutions?

Question 13 of 15

Please indicate below that you are aware that Dr. Sara and Advantage Body Solutions are cash-based fee-for service practices and do not accept insurance.  

A

I am aware.

Question 14 of 15

Which option best describes the role you see Dr. Sara playing in your care?

A

I'm not sure yet

B

I want to work directly with Dr. Sara in-person in Arizona

C

I want to work with Dr. Sara in a virtual format

Question 15 of 15

Your Contact Information:
 Please provide your Name, phone number, and e-mail address so someone from the office can contact you once your application has been reviewed.

(Please look for communications in your SPAM folder)

Confirm and Submit