Functional Healthcare Solutions For:

ADHD * Autism * Dyslexia * Fatigue * Thyroid * Blood Sugar
Depression * Anxiety * Adrenal * Weight Gain * Fatigue

Bringing Hope & Changing Your Life!

Consultation Request

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Email Address

* Please list your top 4 health concerns.

* Have you been treated for this/these condition(s)?

* Were you satisfied with the results of your treatment?

If you were only somewhat satisfied or not satisfied, what would have made your experience better?

Thank you for taking a few minutes to complete this form.

Dr. Dane will call you personally to schedule a consultation. Calls are made on Tuesdays and Fridays.

In the meantime, please collect any lab results, diagnositc imaging, and/or health records you would like Dr. Dane to review.

* Indicates Response Required