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Atlas Naturopathic

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New Patient Application

First name

Last name

Birthday

Phone

Email

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

How did you learn about us?

Google

Social Media

Friend/Family Member

Other

Please tell us about why you would like to work with Dr. Maloof:

What are your top 3 health concerns that you want to address?

What is your level of commitment to working on your health? (1 = very little)

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What are the 3 actions you're currently taking to support your health?"

What are 2 factors that are currently preventing you from healing?

Would you be willing to make drastic lifestyle or dietary changes to support your healing?

Atlas Naturopathic does NOT bill to insurance. Are you willing to financially invest in your health?

What is one thing in your life that brings you joy?

Congratulations for taking the first step towards better health!

Your application has been received.

A member of the Atlas Naturopathic team will contact you ONLY if you application is accepted.

817 Commercial Street

Rockport, ME 04856

PHONE: 207-466-9079
FAX: 207-466-9104

HOURS:

Mon: 8:00am - 5:00pm

Tue: 10:00am - 7:00pm

Wed: 8:00am - 5:00pm

Thu: 8:00am - 5:00pm

Fri: 8:00am - 12:00pm

Closed Sat. & Sun.

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