If you would like to be considered as a new LENS client with us, please complete the form below and a clinic representative will contact you by phone to discuss becoming a new client further.

Name

First Name

Last Name

Phone

(###)

###

####

Please list and describe your most prominent problems:

How long have you been dealing with the problems listed above?

Are you currently on any medication(s) to combat the problems listed above?

Please list any other information you wish the LENS Practitioner to know:

Please check all that apply. I have had or I'm currently experiencing the following:

Seizures

Tics

Headaches

Cluster Headaches

Migraines

Stuttering

Tourette Syndrome

Explosiveness

None of the above

Please let us know the best day and time(s) to contact you. Please add our number to your contact list so you know we are calling. 615-331-1973

**By submitting this form, you acknowledge that your submission is an expression of interest in our services and does not establish a client relationship, guarantee acceptance as a client, or make you a patient of Sarah Cole at the Center for Proactive Medicine. A team member will review your information and contact you to discuss our services and determine if we are the right fit for your needs.**