Request a Lyme Disease / Tick-Borne Infections Consultation at Wave
*Second opinion requests are always welcome
Patient Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
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Day
Year
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Parent Name
if applicable
Home Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Patient / Parent E-Mail
*
Which program are you inquiring about?
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Second Opinion or Initial Evaluation
Lyme Disease/ Tick Borne Disease
PANS/PANDAS
Tick Bite Package
NeuroLyme Evaluation (neuropathy/neuropsych/ walking assistance)
please select one
Health Information
How long have you had the symptom(s) or condition(s) about which you are consulting us?
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Select one
Less than 1 month
Less than 6 months
6 months to 2 years
2-5 years
More than 5 years
Please briefly describe the nature of concerns.
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Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, please give a general overview.
*
Note: a detailed overview can be discussed if you become a patient
How did you hear about us?
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Current or Previous Patient
Google
Facebook
Instagram
Twitter
Other comments
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Our office will review the information on this form to determine your scheduling needs, then contact you with appointment options. Tip: Save our local (203-442-6740) and Toll-Free # (844-468-5963) to recognize when we call
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