Name * Phone * Email * Diagnosis * - Select -PTSDAmyotrophic Lateral SclerosisChronic Muscle Spasms, All locationsChronic NauseaHIV/AIDS or Immune DiseaseGlaucomaFibromyalgiaChronic Bowel Disease, All typesSeizure Disorder/EpilepsyChronic wasting or Profound Weight LossCancer, Malignant and its treatmentRheumatoid Arthritis/ Lupus/SLEChronic Pain, All types, Any location Age Group * - Select -I am Forever YoungUnder 18 years of age18 to 21 years of age22 to 30 years of age31 to 39 years of age40 to 55 years of age56 to 65 years of age66 to 80 years of ageOver 80 years old When is the best time for you to be seen? (Currently by telehealth videoconferencing) * - Select -Weekends in the afternoonWeekdays in the morningWeekdays in the eveningNeverWeekdays in the afternoonWeekends in the morning Island of Residence * - Select -OahuKauaiBig IslandMauiMolokaiOther Are you a veteran? * NoYesYes with service connected injuriesYes with combat connected injuries Have you completed the online registration? * - Select -Yes, completed and submittedNo, I just want informationI am not human...I am a robot.No, but I intend to complete and submit it soon Do you want to be added to our private confidential email list? * YES NO This is contact information only. I will read the autoresponder letter and make contact with the office if I decide to proceed. * I do NOT understand anything about any of this I am a selfish malicious spam maker who deserves nothing good in life. I am a machine and don't care about humans I DO understand that I need to follow-up if I want to proceed further. Leave this field blank Submit
