Page title

First Name

Last Name

Age

Your Phone Number

2. Which autoimmune disease do you currently have?

3. What enjoyable activities has your autoimmune disease kept you from doing?

4. What do you feel is your biggest obstacle in dealing with your autoimmune disease?

5. Briefly describe what it is that you suffer from day to day with your disease? What can’t you do? What are your limits? How has it affected you or your loved ones?

6. How long have you been using your current approach in your treatment of your disease? What are you currently using to “deal” with your autoimmune disease?

9. Who is the person in your life that supports you the most in dealing with your autoimmune disease?

10. Our team will meet with you at the time you have chosen. Please commit to the meeting by writing "I will commit to being on the call"

11. Whom do we need to thank for the referral?

SUBMIT