Concierge Consultation Intake

I. Personal & Time Sovereignty

• Full Legal Name
• Preferred Phone Number (For direct doctor-to-patient coordination)
• Residential or Office Address (Where the mobile suite will be arriving)
• Preferred Treatment Window:
  Morning (6:00 AM – 10:00 AM)
  Mid-Day (10:00 AM – 2:00 PM)
  Late Afternoon (2:00 PM – 7:00 PM)

II. Clinical Profile & Priority Concerns

• Primary Area of Concern: (e.g., Low Back, Cervical, Sports Recovery)
• Intensity Level: (Scale of 1–10)
• Clinical History: Briefly describe any previous surgeries, imaging (MRI/X-ray), or chronic conditions.
• The Goal: What is your primary objective for this integrated session? (e.g., Pain relief, mobility for an event, neurological reset).

III. Integrated Modality Preferences

• Which advanced therapies are you interested in incorporating today?
  [ ] Chiropractic Precision Adjustment
  [ ] FIAMA Medical Acupuncture
  [ ] Dry Needling with Microcurrent
  [ ] Cold Laser Therapy
  [ ] 3D Kinetic Foot Scanning (for Custom Orthotics)

IV. Logistical Essentials

• Parking Clearance: Do you have a flat driveway or accessible street parking for a Mercedes Sprinter High-Roof van?
• Method of Investment:
  [ ] Credit/Debit
  [ ] FSA/HSA (Flexible Spending Account)