Cognoscopy Request Form

Please complete the following form to request a Cognoscopy Consultation.

"*" indicates required fields

  Personal Information

Name*
MM slash DD slash YYYY

  Medical Background

  Lifestyle & Environment

Do you enjoy competitive activities?*
On a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?*
On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?*

  Additional Information

Physician fees are out of pocket, and they do not participate in any insurance plans including medicare or medicaid. Is this workable for you?*
There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?*
Are you free of substance use such as alcohol or recreational drugs?*