Get Help Now Please take 60 seconds and tell us a little about yourselfName* First Last Name Initial What is Your Age Group* 18-29 30-45 46-55 56-70 71 or over Sex:* Male Female Do you consider yourself overweight?* Yes No If Yes, by How Much?* 5-15 lb overweight 16-25 lb overweight greater than 26 lb overweight Do you have problems sleeping?* Yes No Do you have chronic pain?*Do you have chronic pain? Yes No Do you have problems with anxiety?* Yes No Do you get angry or lose control easily?* Yes No Do you often feel stressed out?* Yes No Check off any of the following disorders you have:*Please Check All that Apply Insomnia Migraine Headaches Fibromyalgia Chronic Fatigue High Blood Pressure Diabetes Depression Panic Attacks Asthma Chronic Pain Substance Abuse Other None of the Above Check off any of the following types of medications you are currently on:*Please Check All that Apply Antidepressants (e.g. Prozac, Effexor) Opioid painkillers (e.g. Norco, OxyContin) Anxiety pills (e.g. Xanax, Valium) Sleeping pills (e.g. Ambien, Lunesta) Muscle relaxants (e.g. Soma, Flexeril) [ ] Stimulants (Adderall, Ritalin) Other None of the Above Which of the following services are you interested in:*Please Check All that Apply NESP program for Opioid Detoxification NESP program for Chronic Pain IV wellness protocols for rejuvenation, stress, maintenance (multivitamin, glutathione, amino acid, zinc, infusions, etc.) IV Ketamine protocols for chronic pain, PTSD, depression Other IV protocols (e.g. high dose Vitamin C, magnesium) Please tell us anything else about yourself you feel is important and what you would like to accomplish:Please be as detailed and honest as possible, We are here to help and assist you. The more we know will allow Us to make the best use of Your time during the initial Skype Consultation.How did you hear about the NESP Program* Google Search Opioid Addiction Health News Banner Display Referral from friend or family member Radio Television Other Terms of Initial Skype Consultation*This must be checked and by checking the box you agree that the initial Skype consultation is $99.95 for 30 minutes and is paid prior to the appointment. The confirmation of the Skype appointment does not obligate you to participate in or purchase any of the NESP programs or IV protocols. The cost of the consultation will be applied to any service you participate in. If you do not participate in any NESP program or iV protocol the cost of the consultation is non-refundable.. I Agree CAPTCHAPlease Enter Requested InfoPhoneThis field is for validation purposes and should be left unchanged.
