NPI Application What's your first name?* What's your last name?* Phone Number*Email D.O.B.*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about CMass Health and Wellness, MD?*What are your top health concerns that you would like us to help you overcome?*Why is this goal important to you, and what do you think is stopping you from accomplishing it?*Do you consider yourself coachable?* Yes No Do you have a supportive spouse, significant other, or friend to support your personal goals?* Yes No Who else have you worked with?* Functional Medicine Practitioner Medical Doctor/Osteopathic Doctor Medical Specialist Naturopathic Doctor Traditional Chinese Medicine Nutritionist/Dietician Personal Trainer Chiropractor Personal Development Coach Other: What functional lab testing have you done previously?* Functional Stool Testing Organic Acids Testing Adrenal/Cortisol Testing Genetic or Genomic Testing Hormone Testing Food Sensitivity Testing Heavy Metal Testing None Other Considering your past treatments, what would you like to improve or do differently moving forward?*Are you willing to do what's necessary to reclaim your health? (This may include dietary modifications, functional lab testing, lifestyle and environmental modifications, etc) Yes No I understand CMass Health and Wellness, MD is not contracted with any health insurance company and that the cost of the discovery call is non-negotiable and non-refundable. Yes, I understand that CMass Health and Wellness is not contracted with any health insurance company. Unfortunately, I need a clinic that will take my health insurance for all doctors visits. In your opinion, what makes you a good fit for our practice?*
