Schedule A Free Consult Please enable JavaScript in your browser to complete this form.Name of individual seeking consultation: *Patient - First and Last Name: *Relation to the Patient: *For MyselfFor a family memberFor a friendOther (If Other, please explain below in Additional History box)How did you hear about us/referred by? *Patient Age *Phone Number: *Your Email *State: *Zip CodeIf the program is out of network with your health insurance/self-paid (or you can get partial reimbursement) would you still consider enrollment into the program as an out-of-pocket payment arrangement? *YesNoWhat is your diagnosis?Our program can help with the cascade of symptoms for POTS/Dysautonomia but not to conduct diagnostic testing for an official diagnosis. Would you still like to have a consultation?YesNoPlease have someone contact me to set up a free consultation with Dr. Kyprianou to determine if this is the right program for me.YesNoThroughout the week, what timings are available for your consultation? MorningsAfternoonsAll dayDoesn't ApplySubmit
