Consent to share information and limitations of this application
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Please check the following. This indicates your consent to sharing limited but personal information with Dr. James R. Conway, ND via an online platform. This releases Dr. Conway and the Family Health Clinic from any liability in relation to filling out this form. Filling out this application form does not initiate a doctor-patient relationship between you and Dr. Conway. You will be contacted (typically within 1-2 weeks) with a response.
Age
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Please select whether you are an adult or minor. *Minors will need a guardian to apply for them.
Name (of applicant)
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First Name
Last Name
Phone number
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(###)
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####
Email
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Referring Professional
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Please indicate whether you are applying on your own or at the recommendation of a referring professional.
Health Concern(s)
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Please briefly highlight your key health concerns
Sex
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Currently experiencing
Select all that apply
Duration of symptoms
Please indicate how long you have had your health concerns
Diagnosis
Please indicate where you are in the process of getting a diagnosis
Mold (mycotoxin) related illness
Please note if you know or suspect toxic environmental mold is a factor in your health. Select all that apply.
Diagnostic Tests
Please note which testing has been done (select all that apply)
Healthcare Providers
Please note which healthcare providers you have previously seen or are currently seeing for your health concern. Select all that apply.
Considerations
Please make note of any special information that Dr. Conway should know when reviewing your application
