New Patient Contact & Registration Form

The following information is important in helping us get to know you and your needs. Please answer each question as completely as you can required fields are marked with an *), and when you have finished, be sure to press the SUBMIT button at the bottom of the page

Please enter your information below.

Name*:

Date*:

Age*:

Sex*:	Male Female

Date of Birth*: (including year)

Time of Birth: (if known)

Place of Birth:

Address1 *:

Address2:

City *:

State *:

Zip *:

Telephone *:

Cell Phone:

Email Address *:

Referred by:

Current Medications/Treatments:

Do you know how to eat for good hormonal balance (insulin, leptin, cortisol, growth hormone)?		Yes No

Do you know how to exercise efficiently for the best hormonal response?		Yes No

Are you comfortable with your breathing?		Yes No

Do you sleep well?		Yes No

Are you effective at diffusing stress and shifting yourself to a state of ease?		Yes No

Do you engage in creative activities (word, music, image)?		Yes No

At Lapis Light Natural Health we honor you as the ultimate authority for yourself while providing the practical tools and knowledge you need to be effectively empowered as your own healer. Therefore your wishes and intentions are paramount.

What do you want to accomplish for yourself? What do you want help with? What do you need?

What else would you like Dr. Miller to know?

Please be patient – it may take a few seconds to process your submission… You'll get a ‘thank you’ message when the transmission is complete.

We invite you to subscribe to our Lapis Light E-mail Alerts—occasional messages when there is something important to announce.