Booking Form -

First Name*

Last Name*

Advocate’s Name*

Address

Phone

Email*

Name of Primary Care Physician

Primary Care Physician Address

Primary Care Physician Phone

Primary Care Physician Email Address

Specialty Physicians or Health Care Professionals

Address

Phone

Email

Preferred Hospital or Medical Center

Insurance – PPO

Insurance – HMO

Reason for Inquiry

What do you hope to gain from our sessions?

I understand that our sessions are educational only and that Dr Werner will not diagnose, treat, or prescribe for my medical condition. Our relationship is that of a teacher and student and not a doctor and patient.