Apply Today Treatment Application Form Name* First Last Email* PhoneCell / Alternate PhoneAgeHeightWeightEmergency ContactAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country How did you hear about us?* Facebook Ad Searched on Google, Bing, Yahoo, etc. Instagram/Twitter/Youtube/Google Plus A friend referred me to you Other If you heard about us through a friend or other, please provide the contact's name or source herePrimary Drug of AddictionBrief history of your addiction or condition you are seeking treatment for.BriefList of Medications: Include daily dosagesList of all non-prescribed medications / or street drugs used in the past 30 days.List of medications prescribed, but, not takingList of all supplements / performance enhancers currently taking / or have taken in past month.List of all foods / medications you are allergic to.List any major surgeries you have had, including approximate date.Do you drink alcohol?YesNoIf Yes, how much and how often?Do you smoke?YesNoIf Yes, how much per day?Do you have a history of myocardial infarction or heart disease? If so, explain.Do you have hypertension or hyp-tension?YesNoDo you have a history of seizures?YesNoDo you have a history of vascular disease, including aneurysms? If so, how is it being treated?Do you have a history of embolism, problems w/ blood clotting or recent trauma, including the pelvis or legs? If so, please explain?Do you have diabetes?YesNoAre you insulin dependent?YesNoDo you have hypoglycemia? If yes, please explain.Do you have fainting spells or get dizzy upon getting up suddenly? If so, please explain.Do you have a history of ulcerate colitis, Cronin's Disease, bleeding or peptic ulcers? If yes, please explain.Do you have any type of hepatitis, including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonina levels, etc . . .? If yes, please explain.Do you consider yourself to be depressed? If yes, please explain.Have you ever tried to commit suicide? If yes, please explain.Have you ever been admitted to a psychiatric hospital? If yes, please list approximate dates and condition you were treated for.Do you have any type of brain damage, including traumatic or closed head injuries w/ or w/o unconsciousness or seizures? If yes, please explain.Are you asthmatic? If yes, do you use an inhaler?Do you suffer from or have any of the following physical conditions? Check all that apply. Diabetes Slow Heart Rate Heart Disease Excessive Menstruation Nausea Renal Disease Stroke Liver Problems Heart Problems Painful Menstruation Numbness Shaking Muscle Spasms Hepatitis A, B or C Jaundice Respiratory Problems Swelling Varicose Veins Dizzy Spells Nerve Damage Bleeding History of Seizures Low Blood Pressure Cancer Diarrhea Tuberculosis Heartburn History of Ulcers Thyroid Problems Loss of Menstruation Joint Pain Back Problems High Blood Pressure Constipation Stomach Problems Urinary Problems Asthma Fainting HIV Positive / Aids Shortness of Breath Obesity Additional CommentsDo you suffer from or have any of the following conditions? Check all that apply. Diabetes Slow Heart Rate Heart Disease Excessive Menstruation Varicose Veins Dizzy Spells Nerve Damage Bleeding History of Seizures Low Blood Pressure Cancer Diarrhea Tuberculosis Heartburn Hepatitis A, B or C Jaundice Respiratory Problems Swelling Back Problems High Blood Pressure Constipation Stomach Problems Urinary Problems Asthma Fainting HIV Positive / Aids Shortness of Breath Obesity History of Ulcers Thyroid Problems Loss of Menstruation Joint Pain Nausea Renal Disease Stroke Liver Problems Heart Problems Painful Menstruation Numbness Shaking Muscle Spasms Untitled First Choice Second Choice Third Choice PhoneThis field is for validation purposes and should be left unchanged.