Name * Phone * Email * Diagnosis * - Select -Amyotrophic Lateral SclerosisSeizure Disorder/EpilepsyHIV/AIDS or Immune DiseaseCancer, Malignant and its treatmentChronic Pain, All types, Any locationChronic Bowel Disease, All typesChronic wasting or Profound Weight LossRheumatoid Arthritis/ Lupus/SLEChronic NauseaGlaucomaPTSDFibromyalgiaChronic Muscle Spasms, All locations Age Group * - Select -I am Forever YoungUnder 18 years of age18 to 21 years of age22 to 30 years of age31 to 39 years of age40 to 55 years of age56 to 65 years of age66 to 80 years of ageOver 80 years old When is the best time for you to be seen? (Currently by telehealth videoconferencing) * - Select -Weekends in the morningWeekdays in the afternoonWeekdays in the eveningWeekends in the afternoonWeekdays in the morningNever Island of Residence * - Select -OahuKauaiBig IslandMauiMolokaiOther Are you a veteran? * NoYesYes with service connected injuriesYes with combat connected injuries Have you completed the online registration? * - Select -No, I just want informationNo, but I intend to complete and submit it soonYes, completed and submittedI am not human...I am a robot. Do you want to be added to our private confidential email list? * YES NO This is contact information only. I will read the autoresponder letter and make contact with the office if I decide to proceed. * I am a machine and don't care about humans I DO understand that I need to follow-up if I want to proceed further. I am a selfish malicious spam maker who deserves nothing good in life. I do NOT understand anything about any of this Leave this field blank Submit
