Legal Name*

First Last

Patient Status*

Is this a returning or new patient for Discovery Health Healing Center

Date of Birth*

Email*

Mobile Phone Number*

Discovery Health Services Signup*

Consult
Food Testing
IV Services (IM Shots, IV Drips, Lab Draws)

Please confirm your services you are selecting are included in the Veriha health plan.

Schedule Consult?*

Let us know if we should contact the patient for this consult – or if the patient will be contacting the DHHC office to schedule.

Food Test Kit Delivery*

How will the patient receive their Food Test Kit?

IV Service Selection*

Please select the IV Service Type the patient is interested in. If the IV service is to be performed at DHHC Office select the option to have the patient contacted or if the patient will call DHHC.

Schedule IV Services?*

Let us know if we should contact the patient for this IV Service – or if the patient will be contacting the DHHC office to schedule their IV Service.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Other Notes of Significance

Please enter any additional notes that might be of significance to this patients needs – please do not enter any personal medical history that would be considered confidential.

Veriha Services

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