The Membership Application

Please fill out this form and tell me the why behind the reason you would like to work together. The more information you give me, the better I am able to decide if we will be a good fit and how I can best help you.

Name

First Name

Last Name

Email

Phone

Country

(###)

###

####

What Country or if inside the United States, which state do you live?

This will help me know what services I can offer you based on your location.

Reason for wanting the membership

Tell me your health goals...Please provide a brief summary of your current health issues, how you are feeling, and any past diagnosis

What do you hope to accomplish with Dr. Burklund?

(click all that apply)

Get a second opinion on previous diagnoses

Identify root causes of my symptoms

Become more in tune with my body

Get a holistic view about my health and my conditions

Change my lifestyle and integrate mind body practices

Get adjunctive naturopathic care to complement my care plan

Optimize my current supplement/vitamin plan

What other treatments or strategies have you tried to address your health concerns?

(Provide a brief list or description)

Are you currently prepared to invest in improving your health?

Yes, I would like to purchase the membership now

Not quite, I need more information and have some questions

What’s Next?

We will review your health conditions and see if you’re a good fit for the membership program. You will be contacted by our team shortly to discuss the next steps.

Information & Services Guide

click image to download

The Membership Application

Thank you.

We’ll be in touch.

What’s Next?