HYLANE™ Treatment Form "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.01 • Personal InformationName* First Last Email* Phone*City of Residence*What is your age?*02 • Medical BackgroundPlease list your main symptoms:*What results are you seeking?*03 • Lifestyles & ActivitiesOn a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?* 1 2 3 4 5 On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?* 1 2 3 4 5 Physician fees are out of pocket, and they do not participate in any insurance plans including medicare or medicaid. Is this workable for you?* Yes No There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?* Yes No Are you free of substance use such as alcohol or recreational drugs?* Yes No Have you engaged in self-destructive behaviors (e.g., self-harm, anorexia, substance abuse)? Please elaborate:*How were you referred to us: Physician Dr. Mark Hyman's Podcast Cleveland Clinic Georgetown Univ School of Medicine
